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Wiki Infusion coding question

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shihtzuaddict71

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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?
 
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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.
 
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