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Infusion confusion-how would this be coded?

  1. #1
    Everett, WA
    Default Infusion confusion-how would this be coded?
    Exam Training Packages
    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

    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

  2. #2
    From the limited information you have provided...
    assuming the documentation is there for a 99213,
    I would code:

    96372 is the administration and the IV's include administration. Refer to your CPT book under the infusion heading.

  3. #3
    North Carolina
    Could you code 96374/96375 for pushing the meds? I'm questioning for my own clarification.

  4. #4
    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.

  5. #5
    North Carolina
    Well... how in the world did I miss that??

    Maybe it was the statment that an employee made earlier to me..." Ya we age, we get older"......... Yes...she was dead serious.

  6. #6
    LOL -- I know the feeling...

  7. #7
    Quote Originally Posted by rebeccawoodward View Post
    Could you code 96374/96375 for pushing the meds? I'm questioning for my own clarification.
    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...


  8. #8
    North Carolina
    See if this link helps...I'm still reading it and finding it helpful.

  9. Default 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.

  10. #10
    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.


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