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Mastering Injection andInfusion CodingAudio Seminar/WebinarFebruary 12, 2009Practical Tools for Seminar Learning Copyright 2009 American Health Information Management Association. All rights reserved.
DisclaimerThe American Health Information Management Association makes norepresentation or guarantee with respect to the contents herein andspecifically disclaims any implied guarantee of suitability for any specificpurpose. AHIMA has no liability or responsibility to any person or entitywith respect to any loss or damage caused by the use of this audioseminar, including but not limited to any loss of revenue, interruption ofservice, loss of business, or indirect damages resulting from the use of thisprogram. AHIMA makes no guarantee that the use of this program willprevent differences of opinion or disputes with Medicare or other thirdparty payers as to the amount that will be paid to providers of service.As a provider of continuing education the American Health InformationManagement Association (AHIMA) must assure balance, independence,objectivity and scientific rigor in all of its endeavors. AHIMA is solelyresponsible for control of program objectives and content and the selectionof presenters. All speakers and planning committee members are expectedto disclose to the audience: (1) any significant financial interest or otherrelationships with the manufacturer(s) or provider(s) of any commercialproduct(s) or services(s) discussed in an educational presentation; (2) anysignificant financial interest or other relationship with any companiesproviding commercial support for the activity; and (3) if the presentationwill include discussion of investigational or unlabeled uses of a product.The intent of this requirement is not to prevent a speaker with commercialaffiliations from presenting, but rather to provide the participants withinformation from which they may make their own judgments.AHIMA 2009 Audio Seminar Series http://campus.ahima.org/audioAmerican Health Information Management Association 233 N. Michigan Ave., 21st Floor, Chicago, Illinoisi
FacultyJugna Shah, MPHJugna Shah, MPH, president and founder of Nimitt Consulting, is a nationallyrecognized expert in ambulatory payment reform. Ms. Shah has extensive experiencehelping providers understand and address the clinical, financial, and operationalimplications of Medicare’s implementation of the OPPS based on APCs.Christi Sarasin, CCS, CPC-H, FCSChristi Sarasin, CCS, CPC-H, FCS, is an independent consultant with over 27 yearsof experience in health information management. With over 14 years at a 350bed acute care hospital, Ms. Sarasin's hands-on experience in the variousoperational processes of the HIM department has given her a broad perspectiveof the global medical record workflow processes and the outside influences thatimpact coding, reimbursement and compliance.AHIMA 2009 Audio Seminar Seriesii
Table of ContentsDisclaimer . iFaculty . iiOverview . 12009 Drug Administration Update . 2Drug Administration APC Codes Bar Graph – 2008 and 2009 Comparison . 22008 vs. 2009 APC Payment Rate Comparison of “Initial” DrugAdministration Services Only . 32009 CPT Drug Administration Code Update . 3Hydration, Therapeutic, Prophylactic and Diagnostic Injection and Infusion Codes . 4Review of Drug Administration Concepts that Remain in Place for 2009 . 4-5A Review of Ongoing Issues . 5Time Documentation for Drug Administration Services. 6What is Considered Valid and Complete Documentation toSupport the Charging of Drug Admin Services? . 6-7What Should Be Reported When No Stop Time is Provided for the Infusion Service? . 8Dates of Service for Drug Administration Services . 8-9Modifier -59 . 9Medically Unlikely Edits (MUEs) . 10-11Published Hospital Outpatient MUE Limits for Drug Admin .11New NCCI Edits Implemented January 1, 2009 .12New NCCI Edits Expected for January 1, 2009 .12Drug Admin NCCI Edit that CANNOT Be Bypassed with a Modifier .13Sample of Drug Admin NCCI Edits That CAN Be bypassed with a Modifier .13Making Sense of it All .14The Good Ol’ Days .14The Ground Rules .15Key Factors . 15-17The Hierarchy .17All the King’s Men.18The Players within the Hierarchy .18The Jesters .19ACEs HIGH .19With Rare Exception Chemo Administration Is The More Complex Service .20KINGs.20Anti-neoplastic Drugs Administered for Non-cancer Diagnoses .21Monoclonal Antibody Agents .21Other Biologic Response Modifiers for Non-cancer Diagnosis .22The KINGs Hierarchy .22The Hierarchy .23QUEENs .23The QUEENs Hierarchy .24The Hierarchy .24(CONTINUED)AHIMA 2009 Audio Seminar Series
Table of ContentsJACKs.2510s.259s.26The Hierarchy . 26-27The Players within the Hierarchy .27The Hierarchy of the Lower Court .28WILD CARD .28All the Kings Court .29Or Put Another Way .29Let’s Play .30The Variables within the Hierarchy.31Let’s Play . 31-32Bolus.32Let’s Play .33Therapeutic Infusions . 33-34Hydration Infusion . 34-35Carry-over Infusion Time .35The Rules . 36-39Odds and Ends .40Tricks of the Jester .40Let’s Play .41Riddle Me This .41Riddle Me That .42Priority Areas for Compliance .42Data Transfer .43Process Improvement .43Auditing Drug Administration Services . 44-45Auditing Drug Administration Services: Isolating and Solving Problems .46Resources .46Audio Seminar Discussion and Audio Seminar Information Online .47Upcoming Audio Seminars .48Thank You/Evaluation Form and CE Certificate (Web Address) .48Appendix.49CE Certificate InstructionsAHIMA 2009 Audio Seminar Series
Mastering Injection and Infusion CodingNotes/Comments/QuestionsOverview 2009 Drug Administration Update2008 – 2009 Rate ComparisonQuestions that Keep Coming UpMedically Unlikely Edits (MUE)New NCCI Edits as of 1/1/09Time DocumentationWhat is Valid and Complete DocumentationDates of ServiceRevenue and ComplianceSolving Problems1Overview (cont.) Making Sense of it AllThe Ground Rules for DocumentationKey FactorsAll the King’s MenThe JestersThe Members of the CourtModifier -59The RulesOdds and EndsAreas for ComplianceData TransferProcess ImprovementResourcesAHIMA 2009 Audio Seminar Series21
Mastering Injection and Infusion CodingNotes/Comments/Questions2009 Drug Administration Update OPPS/APC grouping and payment changes for2009 6 drug admin APC groups collapsed to 5 APC payment rates appear better but don’t bemisled Still no separate APC payment for certain CPT codes Coding related changes for 2009 meansoperational impact New CPT numbers for some codes Revised CPT section headings/titles More NCCI edits expected to impact drug adminclaims Tip: Be sure your CDM, charge tickets/forms, etc. are updatedto reflect the new codes for 200934AHIMA 2009 Audio Seminar Series2
Mastering Injection and Infusion CodingNotes/Comments/Questions2008 vs. 2009 APC Payment RateComparison of “Initial” DrugAdministration Services Only 187 200 149 150 114 114 128IVPB 100 73 51 36 50IVPCHEMOHYDRATE 02008200952009 CPT Drug AdministrationCode Update Hydration, therapeutic, prophylactic anddiagnostic service CPT codes have beenrenumbered 2008 CPT code numbers 907XX change to 963XX in 2009 Hydration New code numbers, but all rules/instructions remainthe same “Do not report intravenous infusion for hydration of 30minutes or less” moved under the initial hour code ratherthan under the each additional hour code. Some other sections renamed in the 2009 CPTbook6AHIMA 2009 Audio Seminar Series3
Mastering Injection and Infusion CodingNotes/Comments/QuestionsComparison of 2008 vs. 2009Hydration, Therapeutic, Prophylactic andDiagnostic Injection and Infusion Codes2008 CodesNew 2009 Codes Hydration 90760/90761 Hydration 96360/96361 Therapeutic intravenousinfusions 90765-90768 Therapeutic intravenousinfusions 96365-96368 Therapeutic subcutaneousinfusions 90769-90771 Therapeutic subcutaneousinfusions 96369-96371 Other, therapeutic, prophy., dx,injection/infusion services 90772-90776 Other, therapeutic, prophy.,dx, injection/infusion services 96372-96376 Unlisted code 90779 Unlisted 963797Review of Drug AdministrationConcepts that Remain in Place for 2009 The CPT guidelines and hierarchy must befollowed One code in each category of intravenous infusionand injection drug administration codes designatedas the “initial” service Order of service delivery does NOT determine what is“initial” Typically only one “initial service” will be reported perencounter unless more than one IV access site chemo services are primary to therapeutic, prophylactic, anddiagnostic services, which are primary to hydration servicesInfusions are primary to pushes, which are primary toinjections.The hierarchy does not apply to physician reportingThe hierarchy does not apply to SQ/IM injections (andinfusions), only intravenous injections8AHIMA 2009 Audio Seminar Series4
Mastering Injection and Infusion CodingNotes/Comments/QuestionsReview of Drug AdministrationConcepts that Remain in Place for 2009 Time Documentation is Critical andDrives the Accuracy of the CodesReported. Less than 15 minutes More than 15 minutes 31 minutes to 1 hour15 to 90 minutes versus more than 90minutes 30 minutes since the last reported push Etc.9A Review of Ongoing Issues Time documentation What is considered valid and complete? What should be reported when a stop time is notpresent? Reporting drug administration services thatcross date of service Can multiple initial service codes be reported? What date of service should the additional hoursof infusion be reported? Reporting modifier -59 MUEs and NCCI edits10AHIMA 2009 Audio Seminar Series5
Mastering Injection and Infusion CodingNotes/Comments/QuestionsTime Documentation forDrug Administration Services Physician and nursing documentation is thekey without which accurate charging cannotoccur Typically, hospital documentation forinfusion services reflects the substancebeing infused and the flow rate but this isnot enough Drug administration services that referencetime are in fact “time-based” codes,therefore documentation should support thebilled charges11What is Considered Valid and CompleteDocumentation to Support the Chargingof Drug Administration Services? Some answers: Per AMA – “Infusion time is measured when theinfusate is actually running: pre and post time arenot counted. It is recommended to documentinfusion start and stop times.” Per CMS IOM 100-4, Chapter 4, §230 – Hospitals areto report codes according to CPT instructions. CPTinstructions are to use the actual time over whichthe infusion is administered to the beneficiary fortime-specific drug administration codes. CMS – Indicates that it has the expectation thathospitals will document time otherwise CMS has adifficult time understanding how services wouldbe billed appropriately.12AHIMA 2009 Audio Seminar Series6
Mastering Injection and Infusion CodingNotes/Comments/QuestionsWhat is Considered Valid and CompleteDocumentation to Support the Chargingof Drug Administration Services? (cont.) AdminaStar Dec 2006 FAQ #9: “ the important thing to remember is that areviewer must be able to determine the actualamount of time a medication infused from therecords, not just the ‘ordered’ infusion time.” Drug administration codes are “time-based” codes,therefore a “time-frame” should be clearlydocumented Kansas Medicare—FAQ from December 2006: “.Documenting the actual times would carve outany non-infusion time between each bag that ishung. It is this intermediary’s interpretation thatthe actual infusion start and stop times shouldalways be documented.”13What is Considered Valid and CompleteDocumentation to Support the Chargingof Drug Administration Services? (cont.) WPS Medicare 2008: “Initial IV infusionreported after 15 minutes of infusion.Infusions lasting 15 minutes or lessmust be billed as an IV push. startand stop times must be clearlydocumented in order to requestMedicare payment for infusionservices. In the absence of start andstop time, providers may only requestreimbursement at the IV push level.”14AHIMA 2009 Audio Seminar Series7
Mastering Injection and Infusion CodingNotes/Comments/QuestionsWhat Should Be Reported When NoStop Time is Provided for the InfusionService? What is your practice when a stop time is notreported? CMS does not state anything about what can/cannot bereported if an explicit “stop” time is missing but severalFIs have indicated that an IV push injection can bereported. What does your FI/MAC say? What are the consequences of reporting versus notreporting? Over-payment – compliance issue Under-payment – revenue issue and devaluation of staffeffort No payment if nothing is reported– revenue issue anddevaluation of staff effort What do you consider a best practice with respect tostart and stop times?15Dates of Service forDrug Administration Services What happens when the visit/encountercrosses the midnight hour? Codes should be reported for the entireencounter Report services using the actual date ofservice they were provided. You may see multiple lines of the same CPTcode with different dates Do not report multiple initial service codesbecause the patient stays overnight16AHIMA 2009 Audio Seminar Series8
Mastering Injection and Infusion CodingNotes/Comments/QuestionsDates of Service forDrug Administration Services (cont.) Example: Patient comes to the ED on 02-1509, and hydration is started at 10:00 p.m. Itcontinues until 6:30AM on 02-16-09. Thepatient received an IV push of morphine on02/15/09 and again at 2AM on 02/16/09.What CPT codes and units should bereported?96374 x 12/15/0996361 x 296361 x 696376 x 12/15/092/16/092/16/0917Modifier -59 Modifier -59 is used to: Distinguish between the same services (asreported by HCPCS codes) provided acrossmultiple encounters on the same date ofservice Highlight that two vascular access siteswere started and each was reported withan “initial” service CPT code Bypass MUE and NCCI edits, whenappropriate18AHIMA 2009 Audio Seminar Series9
Mastering Injection and Infusion CodingNotes/Comments/QuestionsMedically Unlikely Edits (MUEs)The CMS MUE program wasimplemented January 1, 2007 with anaim to reduce the paid claims errorrate. Carriers and FIs/MACs adjudicateclaims against MUEs. CMS has contracted with CorrectCoding Solutions, LLC to develop andmaintain MUEs and the NationalCorrect Coding Initiative (NCCI) edits 19Medically Unlikely Edits (MUEs) (cont.) MUE values were established utilizing variouscriteria and are set so that the vast majority ofappropriately reported claims with all units ofservice (UOS) reported on a single line of aclaim will bypass the MUE value. MUE values were evaluated against 100% claims datafrom a six month period in 2006 and reviewed withcontractor medical director workgroups to establishappropriate values. For most codes only very rarely should a claim bereturned to the provider because the UOS exceed theMUE value.20AHIMA 2009 Audio Seminar Series10
Mastering Injection and Infusion CodingNotes/Comments/QuestionsMedically Unlikely Edits (MUEs) (cont.) An MUE for a HCPCS/CPT code is set at what isexpected to be the maximum reported units ofservice under most circumstances All HCPCS/CPTcodes do not have an MUE. The majority of MUE’s were made public on the CMSwebsite on October 1, 2008 and are expected to beupdated quarterly. Published MUEs consist of most of the codes with MUEvalues of 1-3. CMS is not publishing MUE values that are 4 or higherbecause of CMS concerns of fraud and abuse. More information on MUEs can be found on CMS’website /08 MUE.asp21Published Hospital Outpatient MUELimits for Drug AdminHCPCS\CPT 652396542AHIMA 2009 Audio Seminar SeriesHospitalOutpatientServices MUE2113221122122111121112211
Mastering Injection and Infusion CodingNotes/Comments/QuestionsNew NCCI EditsImplemented January 1, 2009 NCCI edits are updated quarterly and thehospital/institutional version is one calendarquarter behind the physician version.In the past, the Outpatient Code Editor (OCE) hasnot applied the NCCI edits from the followingCPT/service categories : anesthesiology, evaluation and management mental health services Expect to see many more line items impacted byNCCI edits starting January 1, 2009 but even moreas of April 1, 2009 Hospital edits can be found /NCCIEHOPPS/list.asp#TopOfPage23New NCCI EditsExpected for January 1, 2009 (cont.) NCCI edits for drug administrationservices provided by hospitals havebeen activated, but right now wemostly see the edits for chemotherapyservices expect that to change as ofApril 1 Some edits can be bypassed with amodifier while others cannot There are also many NCCI edits now activefor E/M visit codes24AHIMA 2009 Audio Seminar Series12
Mastering Injection and Infusion CodingNotes/Comments/QuestionsDrug Admin NCCI Edits That CANNOTBe Bypassed with a ModifierColumn 0964459645096521965229654296570Column 3965239652396523965239652331622Effective DDeletion DModifier20060101 *020060101 *020060101 *019970401 *020060101 *020060101 *020060101 *020020701 20041231 020030701 20041231 020060101 *020060101 *020060101 *020060101 *020060101 *020020701 20051231 020060101 *020060101 *020060101 *020030701 20051231 020060101 *020060101 *020060101 *020060101 *020060101 *020060101 *020010701 *025Sample of Drug Admin NCCI Edits ThatCAN Be Bypassed with a ModifierColumn 1 Column 2 Effective DDeletion DModifier964091190020070401 *1964099077220060101 *1964099077420060101 *1964099652220060101 *1964099918520060101 *1964099920120090101 *1964099921720090101 *1964139077220060101 *1964139077420060101 *1964139640920060101 *1964139652120060101 *1964139918520060101 *1964139920120090101 *1964139920220090101 *1964139921320090101 *1964139921920090101 *1964153650020061001 *1964157589320061001 *1964169076520060101 *1964169077220060101 *1964169077420060101 *1964169918520060101 *1964169920120090101 *1964169921320090101 *1AHIMA 2009 Audio Seminar Series2613
Mastering Injection and Infusion CodingNotes/Comments/QuestionsMaking Sense of it All27The Good Ol’ Days Q-codes ? 90780 9078128AHIMA 2009 Audio Seminar Series14
Mastering Injection and Infusion CodingNotes/Comments/QuestionsThe Ground Rules The Rules for Documentation Must be ordered by a physician Documentation must support medicalnecessity EACH substance administered is Clearly documented, no abbreviations Route and site is easily discernable Start and stop times for EACH substance isdocumented – this is the best practice Amount of EACH substance given isdocumentedCopyright Sarasin Consulting Group29Key Factors Record documentation The service must be ordered by aphysician or other party who is licensedto diagnose and treat Diagnoses must support service(s) asmedically necessary Substance(s) administered clearlydocumented MSOCopyright Sarasin Consulting GroupAHIMA 2009 Audio Seminar Series3015
Mastering Injection and Infusion CodingNotes/Comments/QuestionsKey Factors Charging and Coding Charge TicketsCopyright Sarasin Consulting Group31Key Factors Emergency Room Clinics Other Areas Where Drugs May BeAdministered Post Anesthesia Care Unit ObservationCopyright Sarasin Consulting GroupAHIMA 2009 Audio Seminar Series3216
Mastering Injection and Infusion CodingNotes/Comments/QuestionsKey Factors The Claim Reconciled with record documentationand itemized billCopyright Sarasin Consulting Group33The HierarchyThree Categories of DrugAdministration Codes Chemotherapy Administration Therapeutic IntravenousInfusions/Injections HydrationCopyright Sarasin Consulting GroupAHIMA 2009 Audio Seminar Series3417
Mastering Injection and Infusion CodingNotes/Comments/QuestionsAll the King’s MenPrimary Service (listed by rank) Category I Chemo initiation of prolonged infusion (greater thaneight hours, requiring pump) Chemo infusions Chemo injectionsCategory II Initiation of prolonged infusion (greater than eighthours, requiring pump) Non-chemo, therapeutic infusions Non-chemo, therapeutic injectionsCategory III Hydration infusionsCopyright Sarasin Consulting Group35The Players within the Hierarchy Initial Injections are the exception Key or Primary ReasonCopyright Sarasin Consulting GroupAHIMA 2009 Audio Seminar Series3618
Mastering Injection and Infusion CodingNotes/Comments/QuestionsThe Jesters Initial –Sequential – Infusion Additional hours of infusion of the same drug or of a different drug immediately following an initialinfusion, through the same IV access IV Push – Additional pushes of same drug must be greaterthan 30 minutes apart Concurrent – multiple infusions through the same IV line ofthe same type Reported ONCE per encounterCopyright Sarasin Consulting Group37ACEs HIGHThe code thatbest describesthe primary,most significantservice providedfor the patient.Copyright Sarasin Consulting GroupAHIMA 2009 Audio Seminar Series3819
Mastering Injection and Infusion CodingNotes/Comments/QuestionsWith Rare ExceptionChemo AdministrationIs The More ComplexService,CPT Assistant May, 2007Copyright Sarasin Consulting Group39KINGsChemotherapeutic Services96416 (I) once per day96425 (I)96413 (I)96415 *(S)96417 (S)96422 (I)96423 (S)96549 (C)964019640296409 (I)96411 96420Copyright Sarasin Consulting GroupAHIMA 2009 Audio Seminar Series4020
Mastering Injection and Infusion CodingNotes/Comments/QuestionsAnti-neoplastic Drugs Administeredfor Non-cancer DiagnosesChemotherapy DrugsHormonal AntineoplasticsJ9000 Doxorubicin HCI 10 mgJ0970 Estradiol valerate, up to 40mgJ9001 Doxorubicin HCI,all lipid formulations, 10 mgJ9202 Goserelin acetate implantper 3.6 mgJ9017 Arsenic trioxide 1 mgJ9217 Leuprolide acetatesuspension 7.5 mgJ9040 Bleomycin sulfate 15 unitsJ9219 Leuprolide acetate implant65 mgJ9181 Etoposide 10 mgJ9395 Fulvestrant 25 mgJ9182 Etoposide 100 mgJ9206 Irinotecan 20 mgPartial List Only41Monoclonal Antibody AgentsJ0130 Abciximab 10 mgJ0480 Basiliximab, 20 mgJ1745 Infliximab 10 mgJ2503 Pegaptanib sodium, 0.3 mgJ9055 Cetuximab 10 mgJ9310 Rituximab 100 mgJ9355 Trastuzumab 10 mgPartial List Only42AHIMA 2009 Audio Seminar Series21
Mastering Injection and Infusion CodingNotes/Comments/QuestionsOther Biologic Response Modifiersfor Non-cancer DiagnosisJ0128 Aberelix 10 mgJ0215 Alefacept 0.5 mgJ1440 Filgrastim 300 mcgJ1441 Filgrastim 480 mcgJ2505 Pegfilgrastim 6 mgJ2820 Sargramostim 50 mcgPartial List Only43The KINGs HierarchyTheMoneyThe ServiceThe CodesSIChemo initiation of prolonged infusion (greaterthan eight hours, requiring pump)96416 (I)96425 (I)SS 210.20 210.20Chemo infusions96413 (I)96415 *(S)96417 (S)96422 (I)96423 (S)96549 (C)SSSSSS 210.20 40.40 82.39 210.20 82.39 27.83Chemo injections964019640296409 (I)96411 (S)96420SSSSS 40.40 40.40 143.84 82.39 143.84(Wage adjusted) Add-on code(I) Initial (S) Subsequent (C) Concurrent* Each additional hour beyond first hour minimum 30 plus minutesCopyright Sarasin Consulting GroupAHIMA 2009 Audio Seminar Series4422
Mastering Injection and Infusion CodingNotes/Comments/QuestionsThe Hierarchy Chemotherapeutic Services 96401 – 96549 96417 Once per each additionalsubstance/drug With anti-emetic With hydrationCopyright Sarasin Consulting Group45QUEENsTherapeutic Drug InfusionC8957 (I)96365 (I)96366 (S)96367 (S)96
2009 Drug Administration Update . 2 Drug Administration APC Codes Bar Graph - 2008 and 2009 Comparison . 2 2008 vs. 2009 APC Payment Rate Comparison of "Initial" Drug . book 6. Mastering Injection and Infusion Coding AHIMA 2009 Audio Seminar Series 4 Notes/Comments/Questions
