Injection & Infusion Coding How, What, and Why?

1. Injection & Infusion Coding How, What, and Why? March, 2011

2. 2011 Drug Administration • No operational impact (coding, billing impact) No CPT code changes for 2011. • Hospitals should continue following the CPT rules and hierarchy • Still no separate payment for multiple IV push injections of the same substance/drug (96376) or concurrent infusions (96368) • RAC audits have begun related to time documentation and the use of modifier -59 with injection codes

3. Drugs/Infusion Services • J codes are used for billing specific drug costs and are reimbursable by CMS and other third party payers. • Infusion services (963xx codes) are coded and billed for the administration of drugs via IM, IVP, IVPB, etc. and the nursing staff time involved. J Codes/Drugs Administration Codes

4. Infusion TherapyTake Me Back Through the Years • 2002 – Q0081 – one per visit • 2005 – 90780 – one per visit • 2007 – 90765 – initial service – 1 hour • 2009 – 96365 – initial service – 1 hour

5. Challenges Coders Facewith Injections & Infusions • Timed documentation • What is considered valid and complete documentation? • What should be reported when a stop time is not present? • What drug administration services are/are not considered integral to procedures • Physician Documentation – there MUST be an order that is dated, timed and signed by the physician for the drug.

6. Dates of Service • What happens when the visit/encounter crosses the midnight hour? ( Codes should be reported for the entire encounter) • Report services using the actual date of service they were provided. • You may see multiple lines of the same CPT code with different dates • Do not report multiple initial service codes because the patient stays overnight In transmittal 1702 dated March 13, 2009, CMS stated, “Drug administration services are to be reported with a line item date of service on the day they are provided. In addition, only one initial drug administration service is to be reported per vascular access site per encounter, including during an encounter where observation services span more than one calendar day.”

7. Hierarchy Selecting Initial, Sequential and Concurrent (CPT) (AHIMA) • Chemotherapy infusions • Chemotherapy injections • Non-chemotherapy therapeutic infusions • Non-chemotherapy therapeutic injections • Other injections • Hydration

8. CPT/Coding Hierarchy • The initial code should be selected using a hierarchy whereby: • Chemo services are primary to therapeutic, prophylactic, and diagnostic services, which are primary to hydration services (types of services) • Infusions are primary to pushes, which are primary to injections (routes of administration) • The initial service is reimbursed at a higher rate to cover the costs of initializing the care, such as local anesthesia, tubing/supplies, IV start, etc. • The hierarchy does not apply to physician reporting

9. Exceptions for Initial Service Codes • More than one initial service code may be used when a patient has multiple encounters on the same day of service • More than one initial service code may be used when there are multiple lines in separate veins. • Modifier -59 will need to be applied to both

10. Intravenous and Injection CPT Codes • 96360 Intravenous infusion, hydration; initial, 31 minutes to 1 hour • 96361 Intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure) • 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure) • 96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion, up to 1 hour (List separately in addition to code for primary procedure) • 96368 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure) • 96369 Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to one hour, including pump set-up and establishment of subcutaneous infusion site(s) • 96374 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug • 96375 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure) • 96376 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility (List separately in addition to code

11. Definitions infusion of fluid through a vein or subcutaneously at a regulated rate, replacing or maintaining a fluid balance or adding medications or nutrients. (Hydration, IVPB) direct introduction of a drug or other fluid into the bloodstream or body tissue. (IVP, IM, Subq) Infusion Injection

12. Therapeutic Infusions96365-96366 These are more complex than Hydration with higher risk and increased monitoring. Staff have special training and competency. • Initial or first hour of infusion is from 16 to 90 minutes (applies to therapeutic infusions; does not apply to hydration). • Report add-on codes for additional hours of infusion (beyond the first hour) only after more than 30 minutes have passed from the end of the previously billed hour (i.e., 91 minutes would allow an additional hour to be charged) • (Multiple infusions of different substances/drugs running through the same line may be separately reportable. Time documentation is critical since separate codes exist for initial, sequential, and concurrent infusions. Short duration is still defined as 15 minutes or less and this applies to chemo and non-chemo infusions (report using an IV push code) • These are time based codes – must have a start and stop time.

13. Therapeutic Infusion Times • Report the 1st hour infusion code (96365) when the infusion is greater than 15 minutes • Report additional infusion hours (96366) when more than 30 minutes have passed since the end of the previously billed hour. • Infusions that last less than 15 minutes should be coded as an IVP (96374 /96375).

14. Therapeutic Injections 96374, 96375 and 96376 • CPT definition:“(a) an injection in which the healthcare professional who administers the substance/drug is continuously present to administer the injection and observe the patient, or (b) an infusion of 15 minutes or less” • 96374 – IVP – single or initial • 96375 – each additional IVP of a new substance/drug • 96376 – IVP injections of the same substance or drug • No separate APC attached • Must be over 30 minutes from last IVP of same med

15. IV Push Codes - IVP’s • Each IVP should have a separate time – pushes at the same time should be billed as one • IVP greater than 15 minutes is still a push - Drug pushed over 15 minutes, etc. is still a push (Ex: Ancef pushed over 20 minutes is still 96374 or 96375)

16. Hydration(96360-96361) • Report hydration (96360-96361) when the infusion is greater than 30 minutes • Report the subsequent infusion hour (96361) when documentation states that 31 minutes has passed since the end of the previously billed hour

17. Key Concepts on Hydration • Information from FI/MAC on Hydration : • “Documentation must indicate that the hydration service is a) medically reasonable and necessary and should include the rate of infusion and b) not an integral part of another service such as an operative procedure.” • Medically necessary hydration is to be reported with the add-on hydration code when some other service is reported as initial. • Example: “If a therapeutic intravenous infusion is administered over 16 minutes and the patient was hydrated for 75 minutes, the provider may bill one unit of the hydration add-on CPT code, 96361. • The charges for an administration of 30 minutes or less should be reported with an appropriate revenue code and dollar charge but without a CPT code Per Trailblazer Health Enterprises (MAC J4 TX, OK, CO, NM)

18. Hydration Coding 96360 and 96361 • What Are Hydration Infusions? • Defining “Medically Necessity “with Hydration Infusions • Hydrations 30 minutes or less, are not reported with a CPT. (eg. Bolus) • Ensuring they are not a component of another procedure • Rate it is administered with a clear stop time. (clarifying KVO)

19. Hydrations continued • When Not to code Hydration • When fluids are used solely to administer drug(s) or other substances or the administration of the fluid is incidental hydration and should not be coded, and not a component of another procedure • Keeping the line open (KVO or TKO) • When hydration if performed concurrent to another infusion • When specific time guidelines are not documented • Banana Bags – determined to be coded as IVPB’s. • When there is no stop time.

20. Additional Hydration Notes Per St. Joseph Corporate -All St. Joseph facilities (SJE, CMC, Plainview, Santa Rosa Memorial, PVH, and Redwood) hydrations are to be coded using conventional coding guidelines but medical necessity is not needed to be a determining factor in code selection of hydrations. • How does this impact you coding in one of the St. Joseph facilities? • How does this impact you if coding in a non-SJ facility? • What happens if there is a CCI edit?

21. Drug Administration Integral to Other Services • If the drug administration service is typically performed pre- or post-procedure, then do not separately report. • Examples: Infusion of anesthetic for surgery; pre-op antibiotic injection/infusion; post-op pain and/or nausea injections; injections during CPR; injections for sedation analgesia • Coding Tip : Report pain & nausea IV pushes post-op using rev code 710 and no HCPCS to report the service and cost of providing patient-specific IV pushes • CCI edit manual makes clear that these are considered part of the operative procedure/service • If the drug administration service is not typical for the procedure, then do report it separately • Examples: Anti-thrombolytic injection either pre- or post-surgery; anti-hypertensive injection

22. Drug Administration Services Integral to Other Services Shifting definitions of “integral” is difficult for everyone. Transmittal A-01-13 issued November 20, 2001 Under OPPS packaged services are items and services that are considered to OPPS, be an integral part of another service that is paid under the OPPS… For example, routine supplies, anesthesia, recovery room and most drugs are considered to be an integral part of a surgical procedure so payment for these items is packaged into the APC payment for the surgical procedure. Transmittal A-02-129 issued January 3, 2003 Certain drugs are so integral to a treatment or procedure that the treatment or procedure could not be performed without them. 4th Quarter 2007AHA HCPCS Coding Clinic Although, the antibiotic infusion was specific to the patient and not part of the regular routine, the question remains whether or not the administration of the medication was due to the surgery. Therapeutic intravenous fluids, drug(s) or other substances administered that are integral to the procedure are not separately reported. Therefore, in this situation, the administration was prophylactic and would not be reported separately .

23. Modifier -59 Use • Separate IV/Vascular access sites • Separate visits or encounters during the same day • CCI Edits (seen in the encoder) - CT scans with contrast - CPT surgical procedures (including EKG’s) - Foley catheters Coding Tip: Just because an edit appears that would allow modifier -59, does not mean you should just add it and just because an edit doesn’t surface does not automatically mean that what you are reporting is allowed!

24. Issues in the Emergency Room • IV’s started in the field (hospital specific) • IV’s started for surgical procedures • -59 modifier issues • Hydration and Medical Necessity Issues • No key component information to support diagnostic conclusions and/or diagnostic/therapeutic plans

25. Issues In Observation Services • Will documentation support that the patient is receiving “active” treatment beyond usual post-operative care in order to determine whether the patient should be admitted as an observation patient or admitted as an inpatient? • Do you have an order to admit to OBS? To admit to IP from OBS? • IV D/C’d is not a stop time for hydration or IVPB. (D/C’d on discharge?) (Over one hour)

26. Issues in Ambulatory Surgery • Unexpected circumstances or complications that are outside the normal scope of the procedure are billable under CMS – this must be supported by documentation. • Injections and Infusions that are an integral part of a surgical procedure or a normal protocol for that procedure should not be billed separately.

27. Documentation Red Flags • Extensive, repetitious unnecessary documentation –Unrelated to the presenting problem –“Blown in” records –Documentation by “exception” • CPT defined “work” not demonstrated –Procedures not documented –Level of effort not demonstrated • Circumstances described by modifiers are not demonstrated or documented in the chart

28. Scenario #1 • A 67 year old patient arrives to the ED with Altered mental status, fever, nausea and a headache. After the patient is triaged the MD orders radiology (CT head with contrast), Urine culture, IV meds, 1 Liter 500cc ns and PO antibiotic followed by a Foley. Clinical impression UTI, Fever and hypertension. • 0950 Triage • 0955 PO Tylenol • 0957 Urine clean catch sent to lab • 1005 Dilaudid IVP • 1020 Foley inserted • 1110 To radiology • 1125 Back from Radiology • 1135 Reassess pain continues at 7/10 • 1139 PO Cipro • 1140 Dilaudid IVP • 1145 Zofran IVP • 1147 NS started to run at 125cc/hr • 1255 NS completed • 1310 Foley DC’d • 1450 Pain 0/10 to be discharged home and follow up with PMD • ANSWER – 96374-59 96375-59 96376-59 96361-59 and 51702-59

29. Scenario #2 • NS was started @ 09:30 AM with a documented stop time of 1500.  Patient also received Nitro drip from 10:00 AM with a documented stop time of 1500.  Demerol IV was given @ 12:14 PM.  Phenergan IV was also given @ 1445. • ANSWER 96365, 96366x 4 96375 x 2

30. Scenario #3 • John presents to the ER with nausea and vomiting diagnosed as gastroenteritis. IV Zofran is given at 1310 followed by a bolus of NS and lactate ringers at 125cc per hour (started at 1315) with a stop time of 1500 • What codes do you use? • ANSWER 96374 96361 x 2

31. Scenario #4 • A patient comes in and has IVF from 2120-2158 and then 2215 – 2255. The patient received more IV fluids the following morning from 0128 – 0420. What are the correct codes? • ANSWER 96360 and 96361 – day 1 (2 separate infusions so don’t add time together) 96361 x 3 day 2

32. Scenario #5 • Patient admitted to pre-op and is given IM Ancef and IVP Zofran prior to the procedure. How do you code? • ANSWER - you don’t code any of these – they are integral to the procedure

33. Scenario #6 • ER gave PT Flagyl IVPB at 2320 with no stop time. (left arm) Two IV sites established in ER. • Pt went to OBS then received: • Protonix  IV on day 1 OBS 21:50 and day 2 OBS at 0700, (left arm) • Cipro  IV   day 1 OBS at 22:00 and day 2 OBS at 0900 (right arm) • Flagyl  IV on day 1 OBS at 0600 and 14:00 (left arm) • IV’s D/c’d at 0900 – day 2. • ANSWER 96374 (Flagyl) 96375, 96376 (Protonix) 96374-59, 96376 (Cipro) 96375, 76376 (Flagyl)

34. And Last but not Least….. • Remember… “If it’s not documented, it did not happen” . • “If it’s not documented, it should not be coded and billed” . • “If it’s not documented but it is billed and paid, problems will arise”. • Never Suggest the Following: Changing information after the fact (unsubstantiated back-end fixes) and changing information just to get the claim out the door and/or paid.

35. Resources: • HCPro, Inc. “Injections and Infusions – Solutions for Common Coding”, (Jan,2011) • AMA – CPT, 2011 – Standard Edition • AHIMA“2011Procedure Code Updates,” Audio Seminar/Webinar (Dec, 2010) • “Getting a Line on Intravenous Therapy,” Coding Clinic (4th Q, 2001) • Medicare Coverage—Medical Necessity and Coding Basics – Debra Patterson, MD & Diana Adams, RHIA J-4 MAC Medical Trailblazer Health Enterprises (Oct, 2009)

36. Questions???