Lamon Willis Determining the Hierarchy Determining the Hierarchy Tier 1 Type of Service Chemotherapy Therapeuticprophylacticdiagnostic Hydration Tier 2 Administration Route Infusions Therapeutic ID: 909031
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Slide1
Injections and Infusions
Lamon Willis
Slide2Determining the Hierarchy
Slide3Determining the Hierarchy
Tier 1 – Type of Service
Chemotherapy
Therapeutic/prophylactic/diagnostic
Hydration
Tier 2 – Administration Route
Infusions (Therapeutic)
IV Pushes
Injections (SQ and IM)
Slide4Determining the Hierarchy
There are different determinations for physician services versus facility services.
Infusions are primary to pushes, which are primary to injections.
The hierarchy is to be followed by facilities as well as parenthetical instructions for add-on codes or additional reporting.
Physician (Professional) coding focuses on the primary reason for encounter- not the hierarchy.
Slide5Determining the Hierarchy
Example –
Patient presents to the ED with nausea and vomiting. Patient receives normal saline from 8:00 am to 11:00 am. Also received an IV push injection of Zofran at 10:30 am.
What service will be reported first?
Slide6Determining the Hierarchy
Example –
Patient presents to the ED with vomiting. Patient receives normal saline from 8:00 am to 11:00 am. Also received an IV push injection of Zofran at 10:30 am.
What service will be reported first?
Answer:
96374- IV Push injection of Zofran
.
The hydration is reported secondary with 96361 x3.
Slide7Infusions
Slide8IV Infusion Therapy
Infusions of fluids through a vein at a regulated rate is a method of intravenous (IV) therapy for the purpose of replacing fluid, maintaining fluid balance or adding medications or nutrients.
Hydration
An injection is the
direct introduction
of a drug or other fluid into the bloodstream or body tissue.
Hypodermic (SQ)
Intramuscular
Intravenous or IV push
Slide9IV Infusion Therapy
IV push/bolus – Delivery of medication through an IV push is considered an injection. The injection is given via a syringe either directly into the vein, or into a side port of another infusion IV.
When rapid absorption of a medication is necessary an IV injection may be the selected method of treatment
Slide10IV Infusion Therapy
Assigning the Initial Code
For facility reporting, the hierarchy should be utilized when determining what to code/charge first.
One code in each category of drug administration codes has been designated as the “initial” service
Chemo infusions (96413)
Chemo injections (96409)
Non-chemo, therapeutic infusions (96365)
Non-chemo, therapeutic injections (96374)
Hydration infusions (96360)
Slide11IV Infusion Therapy
CPT instructs only one initial service should be reported even if different services are provided or even if a visit/encounter spans a calendar day.
When administering multiple infusions, injections or combinations, only one “initial” service code should be reported,
unless protocol requires that two separate IV sites must be used
– CPT and NCCI Edits manual
Slide12IV Infusion Therapy
If an injection or infusion is of a subsequent or concurrent nature, even if it is the first such service within that group of services, then a subsequent or concurrent code from the appropriate section should be reported (CPT Manual)
Slide13IV Infusion Therapy
Exceptions To The Rule
Exception 1:
Multiple initial services can be reported when two vascular access sites are started due to medical necessity
Exception 2:
Multiple initial services can be reported when there is more than one encounter on the same date of service and when the same service is provided again.
Slide14IV Infusion Therapy
Case Scenario
An order is given for a patient to come to the hospital twice a day to receive IV infusion of an antibiotic for 10 consecutive days.
Would it be appropriate to use the initial CPT code for
each
session?
Slide15IV Infusion Therapy
Case Scenario
An order is given for a patient to come to the hospital twice a day to receive IV infusion of an antibiotic for 10 consecutive days.
Would it be appropriate to use the initial CPT code for
each
session? Answer:
96365
Slide16IV Infusion Therapy
Additional Hours of Infusion
Guidelines instruct reporting the “each additional hour” infusion codes for infusion intervals
of greater than 30 minutes beyond the 1 hour increment
.
96366 – IV therapeutic infusion; each
add’l
hour
96415 – Chemotherapy administration, IV infusion; each
add'l
hour
96361- Intravenous Infusion, hydration; each
add’l
hour
Slide17IV Infusion Therapy
Sequential
Sequential means “one after another”
One drug infused after another
To report a sequential infusion, an initial infusion must be present/charged and a new drug is infused
Two sequential infusion codes exist; one for a therapeutic/diagnostic/prophylactic infusion (96367) and one for chemotherapy sequential infusion (96417)
Slide18IV Infusion Therapy
Sequential
Sequential means “one after another”
Guidelines instruct reporting the “each additional hour” infusion codes for infusion intervals
of greater than 30 minutes beyond the 1 hour increment
.
96366 – IV therapeutic infusion; each add ’l hour
96415 – Chemotherapy administration, IV infusion; each add 'l hour
96361- Intravenous Infusion, hydration; each add ’l hour
Slide19IV Infusion Therapy
Sequential Example
A patient is admitted to observation and the physician orders an antibiotic IVPB administered over one hour and an infusion of
Dilaudid
. The patient receives the first infusion from 12 pm to 1 pm and the next infusion from 1:30 pm to 2:30 pm.
What codes would be reported?
IV Infusion Therapy
Answer:
96365 (
IV infusion for therapy, prophylaxis or diagnosis; initial, up to 1 hour)
for the first IV infusion of the antibiotic
96367 (
IV infusion; additional sequential infusion, up to 1 hour)
for the second pain medication administration
Slide21IV Infusion Therapy
Concurrent
Concurrent means “at the same time”
Multiple infusions are provided
simultaneously
through the same venous access site.
A single access site with a double lumen catheter with two bags hung.
Infusing through the same access
IV Infusion Therapy
Concurrent means “at the same time”
Drugs aren’t typically mixed in one bag – there must be more than one bag.
“At the same time…not mixed in the same bag…there must be two separate bags.” CPT Assistant, Nov. 2006
Multiple substances mixed in one bag are considered to be one infusion and are not reported as a concurrent infusion. Each substance can be reported separately, but only one administration is reported.
Slide23IV Infusion Therapy
Example:
Chemotherapy
infusion begins @ 9:00 AM until 11:00 AM – if a
non-chemotherapy
infusion was also initiated @ 9:00 AM and ran until 10:00 AM, that would be coded as concurrent (96368).
The non-chemo infusion began at the same time as the chemotherapy infusion
If chemotherapy agents are given concurrently, report the unlisted chemotherapy administration code 96549. Due to evidence of current practice standards, there is not a code at this time for concurrent administration of chemotherapeutic drugs
The American College of Oncology has said it is practically unheard of to have two chemotherapy drugs running in the same line
Slide24Chemotherapy Infusion
Slide25Chemotherapy Infusion
Report chemotherapeutic drug administration for:
Anti-neoplastic drugs administered for non-cancer diagnoses (for autoimmune disorders)
CERTAIN
Monoclonal antibody agents and other biologic response modifiers for non-cancer diagnosis (such as rheumatological disorders)
Remicade
Rituxan
Slide26Chemotherapy Infusion
Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration
Non-radionuclide
Anti-neoplastic drugs and agents for treatment of
noncancer diagnoses (
e.g., for autoimmune conditions)
Monoclonal antibody agents
Infliximab (Remicade)
Methotrexate (Chron’s Disease)
Slide27IV Injections
Slide28IV Injections
Intramuscular
An intramuscular injection is a technique used to deliver a medication deep into the muscles. This allows the medication to be absorbed into the bloodstream quickly.
Intramuscular injections are used when other types of delivery methods aren’t recommended. These include:
oral (swallowed into the stomach)
intravenous (injected into the vein)
subcutaneous (injected into the fatty tissue just under the layer of skin)
Slide29IV Injections
Subcutaneous
A subcutaneous injection is a method of administering medication. Subcutaneous means under the skin.
In this type of injection, a short needle is used to inject a drug into the tissue layer between the skin and the muscle.
Medication given this way is usually absorbed more slowly than if injected into a vein, sometimes over a period of 24 hours.
Slide30IV Injections
Intravenous
Hypodermic injection into a vein for the purpose of instilling a single dose of medication, injecting a contrast medium, or beginning an IV infusion of blood, medication, or a fluid solution, such as saline or dextrose in water.
Allows larger amounts of fluid to be administered and provides means for rapid absorption of medication.
Slide31IV Injections
Intra-arteria
l
Under special circumstances providers do inject substances into an artery, taking all precautions needed to e.g. prevent blood spill or bleeding afterwards, e.g. injecting blood vessel dilatory drugs like Methyldopa in conditions:
where arteries spasm causing lack of blood mostly in hand/feet fingers/toes in Raynaud's disease,
in inoperable tumors sometimes blood clots or other solids are injected into the artery that feeds the tumor, thus causing the tumor to (partially) die off because of the lack of blood feeding it so slow the growth and make it more sensitive to chemotherapy and radiation treatment (i.e., Catheter Embolization), and
then in rare cases chemotherapy is administered into the artery feeding the tumor which might be in the pancreas, liver, and brain.
Slide32IV Push Injection
Hospitals are to report first hour infusion codes after 15 minutes of infusion. Infusions lasting
15 minutes or less
should be billed as intravenous (or intra-arterial) pushes and must be coded accordingly.
A healthcare professional administering an injection is continuously present to administer and observe the patient.
Slide33IV Push Injection
Code CPT 96374 to report an IV push injection of a single or initial substance/drug.
Code CPT 96375 for each additional sequential IV push of a
new
substance drug
Code CPT 96376 for each additional sequential IV push of the
same
substance drug
For facility coding, do not report 96376 for a push performed within 30 minutes of a reported push of the same substance or drug
The same restriction of reporting IV push injections of the same substance/drug does
not
apply to IM/SQ injections (CPT 96372)
Source: Q/A #22 – AHA Coding Clinic for HCPCS, 3
rd
Quarter, Volume 6, Number 3
Slide34IV Push Examples
Patient given four IV pushes of Demerol, you would assign:
96374 or 96375 depending on whether there were other drug administration services provided
and 96376 x3 (provided there was 30 minutes or more between each push).
Slide35IV Push Examples
Patient given one IV push of Demerol and one IV push of Toradol –
Assign 96374 and 96375 (again depending on whether there was another initial service)
If another initial service was already reported, then assign 96375 x2 since these are two
different
substances
Slide36IV Push Examples
Patient given one IV push of Demerol and one IV push of Toradol –
Assign 96374 and 96375 (again depending on whether there was another initial service)
If another initial service was already reported, then assign 96375 x2 since these are two
different
substances
Slide37IM/SQ Injections
Intramuscular injection (IM) – medication is injected directly into the muscle tissue
Subcutaneous injection (SQ) – medication is injected into the subcutaneous tissue
Rules for “same substance” does not apply
Do not report 96372 for vaccines/toxoids
Slide38Hydration Therapy
CPT defines hydrated based on the solutions (pre-mixed, D5-W, normal saline, pre-mixed electrolytes, lactated ringers, etc.)
A specific rate alone does not necessarily point to hydration vs. a therapeutic infusion
Hydration CPT codes cannot be reported for KVO (keep vein open),
heplock
/saline lock
A valid physician order is required for hydration
Medical Necessity
Slide39Hydration Therapy
Reason for hydration must be documented
There are many reasons and different diagnoses that may warrant an order for hydration, including diarrhea, nausea, vomiting, pain, dehydration, etc.
Report separately fluid administration that is medically necessary and can support separately billing the infusion (e.g., correction of dehydration, prevention of nephrotoxicity)
before and/or after
transfusion or chemotherapy
Slide40Hydration Therapy
96360 – IV infusion, hydration; initial, 31 minutes to 1 hour
Do not report 96360 if performed as a concurrent infusion service
Do not report IV infusion for hydration of
30 minutes or less
96361 - …each additional hour
Report 96361 for hydration intervals of greater than 30 minutes
beyond
1 hour
Report 96361 to identify hydration if provided as a secondary or subsequent service after a different initial service is administered through the
same
IV access.
Slide41Documentation Guidelines
Order must be by a physician
Documentation must support medical necessity
EACH substance administered is clearly documented without the use of abbreviations
Route and site is easily discernible
Start and stop times
for
each
substance is documented – this is the best practice
Amount of EACH substance given is documented
Slide42Documentation Guidelines
Physician and nursing documentation is the key - without it, accurate coding/charging can not occur
Typically, hospital documentation for infusion services reflects the substance being infused and the flow rate…but this is not enough
Drug administration services that reference time are in fact “time-based” codes, therefore documentation should support the coding/billing
Slide43Documentation Guidelines
Per
AMA
– “Infusion time is measured when the
infusate
is actually running: pre and post time are not counted. It is recommended to
document infusion start and stop times
.”
Per
CMS IOM 100-4, Chapter 4, §230
– Hospitals are to report codes according to CPT instructions. CPT instructions are to use the actual time over which the infusion is administered to the beneficiary for time-specific drug administration codes.
CMS
– Indicates that it has the
expectation that hospitals will document time
otherwise CMS has a difficult time understanding how services would be billed appropriately.
Slide44Documentation Resources
AdminaStar
Dec 2006 FAQ #9
:
“…the important thing to remember is that a reviewer must be able to determine the actual amount of time a medication infused from the records, not just the ‘ordered’ infusion time.”
Drug administration codes are “time-based” codes, therefore a “time-frame” should be clearly documented
Kansas Medicare—FAQ from December 2006
:
“...
Documenting the actual times would carve out any non-infusion time between each bag that is hung. It is this intermediary’s interpretation that the actual infusion start and stop times should
always be documented.”
Slide45Start & Stop Time Not Documented
CMS does not state anything about what can/cannot be reported if an explicit “stop” time is missing…but several FIs have indicated that an IV push injection can be reported.
The coder(s) typically will recognize this and report an IV push when stop times are not reported.
Slide46Cross Over Dates
What do you do 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
Slide47Cross Over Dates
Clarification to the 2012 CPT Infusion Therapy update on reporting hospital infusion services for outpatient facilities:
“
For continuous services that last beyond midnight, use the date in which the service began and report the total units of time provided .”
The original example in the 2012 CPT book was revised.
Slide48Case Scenario 1
Patient comes to the ED on 02-15-15, and hydration is started at 10:00 p.m. It continues until 6:30AM on 02-16-15. The patient received an IV push of morphine on 02/15/15 and again at 2AM on 02/16/15.
What CPT codes and units should be reported?
Slide49Answer
CPT codes to report would be:
96374 x 1 - 2/15/15 (morphine on 2/15/15)
96361 x 8 - 2/15/15 (hydration 10:00-6:30)
96376 x 1 2/16/15 (morphine on 2/16/15
)
Slide50Case Scenario 2
A physician orders one dose of a medication to be administered intramuscularly (IM) or subcutaneously (SQ). The volume required for this dose exceeds the amount recommended for a single injection, so the nurse must divide the dose into two IM/SQ injections. May we report one or two units of CPT code 96372 to report this service?
Slide51Answer
Report the multiple IM/SQ injections with 96372 (therapeutic, prophylactic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) with the number of injections administered to the patient. Although medically unlikely edits (MUEs) exist for other drug administration codes, CMS has not published MUE limits for 96372.
Slide52Case Scenario 3
A patient is seen at our facility for concurrent chemotherapy administration. Leucovorin is administered intravenously for 2 hours. Oxaliplatin is administered via IV piggyback (IVPB) over the course of 2 hours and 20 minutes concurrently with the administration of Leucovorin. The administration of the Leucovorin is completed 20 minutes prior to the completion of the Oxaliplatin administration. . How should we report the concurrent chemotherapy administration?
Slide53Answer
Oxaliplatin – chemotherapy 2 hours
96413 (initial chemo infusion) x1
96415 (each additional hour chemo infusion) x1
Leucovorin – not considered a chemotherapy drug
96368 (concurrent infusion)
Leucovorin is similar to folic acid and is often administered with chemo drugs.
Used to either protect healthy cells from chemotherapy or to enhance the anti-cancer effect of chemotherapy.
Slide54Case Scenario 4
A patient was seen in the outpatient clinic for drug infusion. The physician ordered antibiotic drug infusion every 12 hours, with the first antibiotic infusion followed by an antifungal drug infusion. The patient received the infusion at 8:00 AM and was permitted to leave the center. The patient then returned later in the day to receive the second infusion at 8:00 PM.
Would it be appropriate to report two initial infusions (code 96365) with modifier -59 appended to represent the second dose?
Slide55Answer
It is appropriate to append modifier -59, Distinct Procedural Service, to the second initial service, whether it is for a second encounter on the same date of service or second site per protocol. In this circumstance,
the second initial service is reported because the patient left the center
and upon returning, another initial infusion is administered
.
It is recommended that you provide medical documentation based on payer policy regarding the use of the same "initial" infusion code on the same date of service with modifier -59 appended.
Slide56Case Scenario 5
Physician orders the following and patient receives the following:
Toradol 30 mg IVP
Zofran 4 mg IVP
Decadron 20 mg IM
Demerol 25 mg IVP
Rocephin 1 gram IVP
Toradol 30 mg IVP
IVF 1 liter NS for 1 hour
Slide57Answer
The facility may report the following:
96374 IVP Toradol;
96375 IVP Zofran;
96372 IVP Decadron;
96375 IVP Demerol;
96375 IVP Rocephin;
96376 IVP Toradol;
96361 IV 1 liter NS