Primary Care Coding Alert

You must meet the 16-minute mark to code for infusions

When your family practitioner performs an infusion involving multiple substances, you need to identify the type of infusion on the claim, or you could risk denials. Further, you-ll need to know which infusion to list as primary, or the claim could wind up being inaccurate. Initial Codes Represent -Main Reason- for Session On multiple-substance infusion claims, you should report the initial infusion with 90765 (Intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; initial, up to 1 hour) and +90766 (- each additional hour [list separately in addition to code for primary procedure])--as long as the encounter meets these parameters, says Sarah L. Goodman, CPC-H, CCP, president and CEO of SLG Inc. in Raleigh, N.C.:

- The drug is being administered for therapeutic, prophylactic or diagnostic purposes.
- The infusion lasts at least 16 minutes.
- The infusion is not considered an inherent component of another procedure, such as a CT scan.
- A healthcare professional is continually present during the session. The physician may report 90766 for -each additional hour- only if the infusion interval is greater than 30 minutes beyond the one-hour increment.

For example, if the patient receives an infusion of a single drug that lasts 1 hour and 45 minutes, the physician would report 90765 for up to one hour and 90766 for the additional 45 minutes.

Don't be fooled: -Initial infusion- does not automatically mean the first drug the FP administers, because payers consider the initial infusion the -main reason- the patient is seeing the FP, says Cindy Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Powder Springs, Ga.

-The chronological order of the drugs, medications and/or substances infused is not important--what is critical is the primary reason for the patient to be there that day,- she says. Hierarchy Comes in Handy for Infusion Sessions As a guide, Goodman uses this -unofficial hierarchy- of infusion services she culled from the APC Weekly Monitor. This list could come in handy when deciding how to code multiple infusion claims:

- Chemotherapy infusions
- Chemotherapy injections
- Non-chemotherapy, therapeutic infusions
- Non-chemotherapy, therapeutic injections
- Hydration infusions. -Regardless of the order in which the FP administers the infusions, report the -initial- code for the service that falls highest on the list,- Goodman says.

Official guidelines: -The initial code is the code that best describes the key or primary reason for the encounter, and should always be reported irrespective of the order in which the infusions or injections occur,- according to Chapter 12, section 30.5E of the Medicare Claims Processing Manual.

Example: The patient presents to the FP's office for chemotherapy treatment, and the FP performs a therapeutic, non-chemotherapy infusion or injection (that is, antibiotics, steroidal agent, antiemetics, narcotics, etc.) followed by [...]