Wiki Infusion confusion-how would this be coded?

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ollielooya

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Hello group!
Here's a paragraph I abstracted from a chart note for a99213 office visit with acute care requested from patient:

IV injection of Toradol 30 mg. and Nubain 50 mg. were given intravenously in an
IV bag. He was monitored for one hour. Headaches resolved. Discharged with a
driver. Vitals at time of DE were (3
given)

Here are the submitted codes from the chart: 99213-25, 96365, 96368, J1885, J2300, 96372. Also feel an extended service code might be applicable. But again, the 96372 is up for dispute, and I'd like to thank the special people from the forum who've recently helped me, Tessa and Rebecca W. IF these codes as submitted ARE wrong, then will be needing to take this up with the doctor, but so NEW to this....the DX is 346.10. So, how would you code this?

Suzanne E. Byrum, CPC-A
 
From the limited information you have provided...
assuming the documentation is there for a 99213,
I would code:
99213-25
96365
96368
J1885
J2300

96372 is the administration and the IV's include administration. Refer to your CPT book under the infusion heading.
 
Rebecca-
my CPT book says "do not report with codes for which IV push or infusion is an integral part of the procedure" for those codes.

In the scenario above, I'd say it's integral and not codeable.
 
Well... how in the world did I miss that?? :confused:

Maybe it was the statment that an employee made earlier to me..." Ya know...as we age, we get older".........:eek: Yes...she was dead serious.
 
rebeccawoodward said:
Could you code 96374/96375 for pushing the meds? I'm questioning for my own clarification. :)
Click to expand...

It appears that the drugs were mixed into the IV solution and infused per the OP's documentation, but these meds can be given IV push. If documentation did not state the use of the IV solution and only the IV meds, would codes 96374/96375 be used?

You guys and gals are so knowledgeable! I am in awe...

J
 
Infusion

If this is all the documentation you have, I would be going back to the nurses for some clarification. You need start/stop times. 'monitoring for an hour' does not translate to an hour of infusion time.
The way it's written it sounds like both drugs were in the same bag, though the toradal says 'injection'. This is a poorly documented infusion.
A billable injection done with an infusion would require a 59 modifier.
 
I would be surprised if Toradol and Nubain were even compatible in the same IV bag. I agree that the documentation is lacking, ktricia. Is there another part of the record for medication administration that can be accessed?


Great link, Rebecca! My favs are filled with your recommendations. :)

J
 
Infusion Vitals

Hi,

Does anyone have any documention stating a minimum of 3 vitals must be taken. I have an office location that states only 2 is necessary. It has been my understanding 3 vitals were needed for documentation and is just good policy. Does anyone have any information on this if at all possible for infusion centers ?

Any help would be great....
 
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