Oncology & Hematology Coding Alert

Everything you need should be right in the MAR.

If you were looking for a quick, easy, and — most important — accurate way to code infusions, and you missed the HEALTHCON 2022 presentation “Injection and Infusion Coding,” then you missed a lot.

Fortunately, Oncology & Hematology Coding Alert was there and was able to bring back this great advice. We’ve also included a chemotherapy scenario to help you get your infusion coding on the right track.

Step 1: Determine Number of Sites and Primary Service Per Site

Before anything else, scour the documentation to find the number of access sites. This means verifying each site and grouping services by site if multiple sites are supported.

Why: “You only code one initial service per IV [intravenous] access site” because “initial services in these code sets are parent codes. The parent codes are weighted heavier, which affects reimbursement,” according to presenter Jessica Trefethen, CPC, CPMA, CCS-P, CCS, senior regulatory billing auditor for MaineHealth in York, Maine. “That’s because the initial services cover the work of establishing the site. The local anesthesia; IV start; access to indwelling IV, subcutaneous catheter, or port; flush; and standard tubing, syringes, and supplies are all bundled. For each access site, there can only be one initial service,”.

Report all other services with add-on codes. Those services are one of the following:

• Additional: The continued infusion of the same drug following a primary or initial service
• Sequential: The infusion of a new drug following a primary or initial service
• Concurrent: The infusion of a new drug at the same time as another drug

Additionally, service administration can be either:

• Subcutaneous (SQ): Applied under the skin
• Intramuscular (IM): Deep into the muscles
• Intravenous (IV): Directly into the vein
• Intra-arterial (IA): Directly into the artery
• Intralesional (IL): Directly into the lesion
• Intracavitary (IC): Directly into the cavity

Hot tip: “A triple lumen catheter counts as one site, even though there are three lumens,” Trefethen noted.

Step 2: Review Medications Administered

In this step, you need to determine the difference between drug classes — whether a drug is therapeutic or chemo/complex — as this will affect your code selection, Trefethen noted. This means the difference between using a code from 96365-96379 for therapeutic, prophylactic, and diagnostic injections and infusions, and 96401-96549 for chemo and other highly complex drugs.

Know this nuance: Knowing that a drug, such as leucovorin, is a chemoprotectant (a drug that limits the toxic effects of a cancer drug and which is often administered simultaneously at chemotherapy sessions) and not classified as a chemo/complex drug, will affect code choice.

Step 3: Determine Times

Here, the two important things to remember are: first, the difference between coding for a push, which is an infusion of 15 minutes or less, and an infusion, which lasts 16 minutes or more, and second, that a unit of time is achieved after the midpoint threshold has been exceeded (i.e., anything over 31 minutes can be coded as an hour).

And Remember These 2 Great Tips

Tip 1: Additional sequential IV pushes of the same substance cannot be captured in the outpatient office setting (POS 11). This is why add-on code +96376 (… each additional sequential intravenous push of the same substance/drug provided in a facility …) is reserved specifically for facility coding.

Tip 2: “Even though it’s a low-value service, hydration is a hassle to get paid, and it can only be captured when everything is just so. It can’t be billed if it is a vehicle for administration; it can’t be billed when it is concurrent; it can’t be billed as KVO [keep vein open]; and it has to run for 31 minutes, meaning there has to be a stop time,” Trefethen cautioned.

This is not to say you cannot bill for hydration. For example, “if you have an order, the hydration serves a medical purpose or volume repletion, and the time for the hydration is at least 31 minutes counted when running by itself, then it may be appropriate to bill for it,” says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, associate partner, Pinnacle Enterprise Risk Consulting Services LLC, Centennial, Colorado.

Test your skills: Try your hand at coding the infusion case on page 3.