Wiki Need Coding Infusions Help

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sandrews21

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Hi Everyone,

I would like some clarity on how to code Infusions. Several Coders in my department have different ways of interpreting Chart notes per the doctor/Practitioner and it's very confusing. When coding for normal saline, when is it appropriate to code 96361? I noticed that some Coders do not use this add-on code when there's documentation that normal saline was given for more than a half an hour. Also, when an Epi-pen is administered, is it appropriate to bill the Admin code of 96372 with this? Below is an example of a similar chart note that I see often:

11:45 22G Angio-cath put on place to left AC, prior to infusion blood return noticed and flushed with 10ml of NS without any complications. As per the Dr., patient received 4mg of Zofran; IV pushed, patient also received 1L of NS, patient tolerated all infusions well. Infusion stopped 1:15 and IV discontinued and pressure band aid applied, no sign or symptoms of infiltration observed.

This was billed as:
99213-25
96374
J2405 Zofran-4 units
J7030 1000 ML Normal Saline
87880

Is this correct? Please provide some clarity:confused:
 
you need a diagnosis to support the use of the 99361 such as dehydration. In this case it appears the IV was started as a convenience in order to administer the IV push medication. In all likelihood after the push was given they simple allowed the NS to empty out. Without a medically necessary reason for hydration, it is not separately billable.
So in the documentation you provided I do not see where you are getting the 99213 or the 87880, Or is it that you have not provided all the documentation?
The IV push is correct and the medication and NS is appropriate.
 
Thanks Debra for responding! Yes, I didn't provide all of the documentation since I was trying to focus merely on the Infusions and it would've been too much to submit. When coding for an Epi-Pen do we need an Admin code of 96372? Would you have coded this chart note as the example below?
 
I have never had an epi pen administered in the office as that is usually patient self administered so I am not sure but I am thinking no. if you are speaking of the chart note you supplied in the first post then assuming all the documentation is there to support the codes yes that is how I would code it.
 
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