Wiki Infusion coding question

[shihtzuaddict71]

If a chemo med is documented as running for 93 minutes, but the order states it is supposed to run for 90, do you bill 96413, 96415 or jus the 96413?

 

[csperoni]

Infusion or not, coding should be based on what was actually performed and documented, not what was planned to be performed. In this situation, I would bill for 93 minutes, so 96413 and 96415.
I will note if I was repeatedly seeing this, I would confirm with the clinical staff regarding the situation, and might suggest clearer documentation moving forward. An explanation about why a slightly longer infusion was required would be helpful.