Oncology & Hematology Coding Alert

These instruction changes aim to answer common infusion admin questions.

At first glance, the CPT® 2012 manual seems to present a completely overhauled set of infusion administration guidelines. But if you're confused about what exactly is new, you aren't alone.

Good news: The guideline revisions fall more under the category of "clarification" than under the category of "change," says Kelly Loya, CPC-I, CHC, CPhT, manager for Sinaiko Healthcare Consulting Inc., a reimbursement services division of Altegra Health. For example, "it provides clarified language regarding when hydration can be billed and how dates of service during an overnight outpatient hospital stay for observation should be reported." So the 2012 guidelines bring better direction supporting what practices should have been doing all along.

The revisions offer a great incentive to review the guidelines, check them against your own coding, and make any adjustments needed to ensure clean, compliant claims. Several highlights are covered below, but be sure to read all of the guidelines for yourself. You'll find the "Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions, and Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration" guidelines located before 96360 (Intravenous infusion, hydration; initial, 31 minutes to 1 hour) in your manual.

Watch for Supported Office/Outpatient E/M Visit

The revised guidelines add details on which E/M codes you may report in addition to the infusion administration codes, said Peter A. Hollmann, MD, AMA CPT® Editorial Panel Chair, at the CPT® and RBRVS 2012 Annual Symposium.

From the 2011 guidelines, you already know that your physician may report a significant, separately identifiable E/M service in addition to the infusion service code by appending modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.

The 2012 guidelines go a step further by stating if a separately identifiable E/M is performed, you should report a distinct "office or other outpatient" E/M service. To underscore the point further, the guidelines list the possible office/outpatient codes:

• 99201-99215, Office or other outpatient visit ...
• 99241-99245, Office consultation ...
• 99354-99355, Prolonged service in the office or other outpatient setting ...

In a typical case, a physician reporting an E/M and infusion admin for the same patient will be performing both in the office setting. This is because physicians should not submit claims for most infusions performed in a facility. As the guidelines state, infusion admin codes "96360-96379, 96402, 96409-96425, 96521-96523 are not intended to be reported by the physician in the facility setting."

Caution: You may notice the guidelines include 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services) as a part of the office/outpatient E/M ranges to be reported with infusion. But keep in mind if the third party is Medicare, a payer who follows Correct Coding Initiative (CCI) guidelines, or a payer obligated to follow Federal Register guidelines, these sources prohibit the reporting of 99211 with infusion/injection administration professional fee services. Additionally, modifier 25 will not bypass the edit. (For more information, see Claims Processing Manual, 100-04, chapter 12, section 30, www.cms.gov/manuals/downloads/clm104c12.pdf).

Review When 2 Initial Codes Are OK

The 2012 guidelines go into more detail than the 2011 guidelines did on the meanings of initial, sequential, and concurrent when used in the infusion code definitions, Hollmann explained. The guidelines also offer practical information on how to apply the codes.

Initial example: Like the 2011 guidelines, the 2012 guidelines state that when administering multiple infusions, you should report only one "initial" service code. (CPT® 2012 adds "for a given date.") The exception under both 2011 and 2012 guidelines is that you may report more than one initial code if protocol requires use of two separate IV sites.

The 2012 definition for initial infusion adds that when "protocol or patient condition" requires two IV sites, you may report a second initial infusion with modifier 59 (Distinct procedural service) appended.

Encourage your providers to document, in a patient-specific order, the medical need for two IV sites when not based on a clinically accepted, standard, medication-specific protocol, experts advise. Also, when provided in this manner, the second IV site should be clearly represented in the infusion nurse's documentation to support the second initial CPT® code selection.

Look: The 2012 guidelines also add helpful information on what does not qualify for a second initial code:

Sequential example: In defining sequential infusions, CPT® points out that sequential refers to administration of a new substance or drug. (There is an exception for facilities: +96376 [Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility (List separately in addition to code for primary procedure)]. Physicians should not report +96376.)

The bottom line is that a "sequential" infusion identifies infusion of a new substance/drug. This is in contrast to a subsequent infusion, which describes the second or subsequent infusion of the same substance/drug (the subsequent code definition typically includes "each additional hour").

Know Which DOS Applies for 2-Day Infusion

As a physician coder, you may not encounter too many midnight infusions, but the updated guidelines offer helpful instructions in case you do. The scenario is more common for facilities.

Continuous: When an infusion begins on one date and continues past midnight to the next date, you should code the infusion just as you would a continuous infusion performed on a single date. Use the start date as the date of service (DOS). For example, if a hydration infusion runs from 11 p.m. on February 3 to 2 a.m. on February 4, you should report 96360 (Intravenous infusion, hydration; initial, 31 minutes to 1 hour) and 96361 x 2 (... each additional hour [List separately in addition to code for primary procedure]). Use February 3 as the DOS.

Not continuous: If staff administers an IV push at 10 p.m. and then another IV push four hours later at 2 a.m., CPT® guidelines state each push should be reported with an initial code. (Assuming of course that each qualifies as the "initial" infusion service.)

Report Hydration Ordered to Prevent Toxicity

The 2012 guidelines offer important pointers for hydration given before and after chemotherapy or other drugs to prevent certain toxicities.

Can you report that hydration? CPT® guidelines say yes. The infusion must meet the minimum time requirement of 31 minutes for you to report a hydration code, the guidelines state.

As a coder, you want to be sure the documentation clearly indicates the physician ordered the hydration to prevent a possible toxicity that the administered drug could cause.

Caution: Don't count fluid running to keep the line open before or after an infusion as hydration time. You also shouldn't report 96360 or +96361 when the fluid is running during another therapeutic infusion.