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Correct Coding forInfusions and InjectionsjRegan Tyler, CPC, CPC-H, CPMA, CEMC, ACS-EM1Agenda The hierarchy facility vs. clinic for infusion coding- Initial, each additional, each sequential, concurrent Documentation of start and stop times Chemo and non-chemo infusion pumps Evaluation and Management (E/M) visitsperformed the same day as infusion services Coding hydration infusion with other infusionservices Blood draws, phlebotomy, and port flushes2Supervision Levels General Supervision - means the procedure is furnished under thephysician’s overall direction and control, but the physician’spresence is not required during the performance of the procedure. Direct Supervision - means the physician must be present andimmediately available to furnish assistance and direction throughoutthe performance of the procedure. It does not mean that thephysician must be present in the room when the procedure isperformed. Personal Supervision - means a physician must be in attendance inthe room during the performance of the procedure.31
Infusion/Injection Servicesperformed in the facility settingFor all infusions reported by the facility, IV pushes and injections arecoded based on a hierarchy. The hierarchy determines whichinfusion service will be coded as the “initial.”Chemotherapy services are primary to therapeutic, prophylactic anddiagnostic services which are primary to hydration.1 Chemotherapy1.2. Therapeutic, prophylactic and diagnostic services3. HydrationInfusions are primary to IV pushes, which are primary to injections.1. Infusion2. IV Push3. Injection4Infusion/Injections performed in theclinic settingThe initial code should be the code that bestdescribes the key or primary reason forthe encounterencounter. The order in whichinfusions and injections occurs, does noteffect which code is the initial.5Chemotherapy vs. NonChemotherapy vs. HydrationChemotherapyChemotherapy administration codes are for theadministration of: Non-radionuclide anti-neoplastic drugs Anti-neoplastic agents for treatment of non-cancerdiagnosis Certain monoclonal antibodiesThese services require direct physician supervision.62
Chemotherapy vs. NonChemotherapy vs. HydrationTherapeutic, Prophylactic and DiagnosticInjections and IV Infusions (Non-Chemotherapy)This category of codes is for the administration of: Therapeutic, Prophylactic, Diagnostic substances/drugsThese services typically require direct physiciansupervision.7Chemotherapy vs. NonChemotherapy vs. HydrationHydrationHydration IV infusions consist of pre-packagedy(examples:(pnormal saline,fluid and electrolytesD5-1/2 normal saline).These services usually require direct physiciansupervision.8Infusion vs. IV Push vs. InjectionInfusionAn infusion is defined as any substanceinfused through any type of line forgreater than 15 minutes and up to onehour.93
Infusion vs. IV Push vs. InjectionIV PushAn infusion of 15 minutes or lessORA injectionAni j ti iin whichhi h whomeverhadministersd i i tthe substance/drug is continuously present10Infusion vs. IV Push vs. InjectionInjectionAny intramuscular, subcutaneous orintra-arterial injection11Administration Code CategoriesEach code in the infusion section of the codebook is defined using one of the followingterms: InitialEach additional hourEach additional sequentialConcurrent Infusions124
Initial Infusion/IV Push The initial code may be chosen based on the hierarchy or based onthe primary reason for the encounter-it depends on where theservice was performed. The order in which drugs/substances are infused or injected doesnot reflect the code choice. Only one initial code is reported per encounter (no matter how manydrugs are administered) unless protocol requires that two separateIV sites be used. There is one initial code in each category of codes (Chemo infusion,chemo IV push, Non-chemo infusion, Non-chemo infusion,Hydration)13Each Additional Hour(Infusions only) These codes are used for any additionaltime beyond the first hour of an infusion. Time must be documented as greater than30 minutes beyond the first hour of initialand/or sequential infusions. This code can be reported with anynumber of units depending on length ofthe infusion14Each Additional Sequential(Infusions or IV Push) For each additional drug that is infusedsequentially to the initial infusion, use the “eachadditional sequential” infusion code. This code can only be billed once per drug forthe first hour of each sequential infusion. For anyadditional time past the first hour (greater than30 minutes) use the “each additional hour”codes.155
Concurrent Infusions Use this code when two substances/drugsin two separate bags/syringes areinfused at the same time through oneaccessaccess. This code can only be billed once perpatient encounter. Only used for non-chemotherapyinfusions.16Infusion 96360 96361Each Additional Hour 96415 96366Subsequent 96417 96367Push Initial9640996374Subsequent Push New 96411Concurrent 96368Subsequent Push Same 96375 96376 (Facilityonly – 30 minapart)CPT CodesChemotherapyIntravenous Infusion 96413-Chemotherapy administration intravenousinfusion technique; up to 1 hour, single or initialsubstance or drug 96415-Chemotherapy administration intravenousinfusion technique; each additional hour 96417-Chemotherapy administration intravenousinfusion technique; each additional sequential infusion(different substance/drug), up to 1 hour186
CPT Codes continued Chemotherapy cont.Intra-Arterial Infusion 96422-Chemotherapy administration, intra-arterial;infusion technique, up to one hour 96423-Chemotherapy administration, intra-arterial;infusion technique, each additional hour 96420-Chemotherapy administration, intra-arterial; pushtechnique19CPT Codes continued Chemotherapy cont.IV Push 9640996409-ChemotherapyChemotherapy administration intravenous,intravenouspush technique, single or initial substance/drug 96411-Chemotherapy administration intravenous,push technique, each additional substance/drug20CPT Codes continued Chemotherapy cont.Injections 96401-Chemotherapy administration, subcutaneous orintramuscular, nonnon-hormonalhormonal antianti-neoplasticneoplastic 96402-Chemotherapy administration, subcutaneous orintramuscular, hormonal anti-neoplastic 96405-Chemotherapy administration; intralesional, up toand including 7 lesions 96406-Chemotherapy administration; intralesional, morethan 7 lesions217
CPT Codes continued Chemotherapy cont.Other 96440-Chemotherapy administration into pleural cavity,requiring and including thoracentesis 96446-Chemotherapy96446 Chthadministrationd i i t ti iintot peritonealitlcavity via indwelling port or catheter 96450-Chemotherapy administration into CNS(intrathecal), requiring and including spinal puncture 96542-Chemotherapy injection, subarachnoid orintraventricular via subcutaneous reservoir, single ormultiple agents 96549-Unlisted chemotherapy procedure22CPT Codes continued Therapeutic, Prophylactic and Diagnostic Injectionsand IV Infusions (non-chemo)Intravenous Infusions 96365-Intravenous infusion, for therapy, prophylaxis, ordiagnosis; initial,initial up to one hour 96366-Intravenous infusion, for therapy, prophylaxis, ordiagnosis; each additional hour 96367-Intravenous infusion, for therapy, prophylaxis, ordiagnosis; each additional sequential infusion, up to 1hour 96368-Intravenous infusion, for therapy, prophylaxis, ordiagnosis; concurrent infusion23CPT Codes continued Therapeutic, Prophylactic and Diagnostic Injections and IVInfusions (non-chemo)Subcutaneous Infusions 96369-Subcutaneous infusion for therapy or prophylaxis;p to one hour,, includingg pumpp p set-upp andinitial,, upestablishment of subcutaneous infusion sites 96370-Subcutaneous infusion for therapy or prophylaxis;each additional hour 96371-Subcutaneous infusion for therapy or prophylaxis;additional pump set-up with establishment of newsubcutaneous infusion sites248
CPT Codes continued Therapeutic, Prophylactic and Diagnostic Injectionsand IV Infusions (non-chemo)IV Push 96374-Therapeutic, prophylactic or diagnostic injection;intravenous pushpush, single or initial substance/drug 96375-Therapeutic, prophylactic or diagnostic injection;each additional sequential intravenous push of a newsubstance/drug 96376-Therapeutic, prophylactic or diagnostic injection;each additional sequential intravenous push of thesame substance/drug (facility only) (IV pushes must begreater than 30 minutes apart)25CPT Codes continued Therapeutic, Prophylactic and Diagnostic Injectionsand IV Infusions (non-chemo)Injections 9637296372-Therapeutic,Therapeutic, prophylactic or diagnostic injection;subcutaneous or intramuscular (SQ/IM) 96373-Therapeutic, prophylactic or diagnostic injection;intra-arterial26CPT Codes continued Therapeutic, Prophylactic and DiagnosticInjections and IV Infusions (non-chemo)Other 96379-Unlisted therapeutic, prophylactic ordiagnostic intravenous or intra-arterial injection orinfusion279
CPT Codes continued HydrationIntravenous Infusion 96360-Intravenous infusion, hydration; initial, 31minutesi t tto 1 hhour 96361- Intravenous infusion, hydration; eachadditional hour28Example # 1Patient presents for weekly chemooutpatient treatment in the hospital. Hereceives: 2 hour infusion of 1st chemo drug1 hour infusion of 2nd chemo drug10 minute non-chemo IV pushIM injection29Example # 11. Determine which service will be the “initial” using thehierarchy.2. Determine where the other services will fall; “eachadditional”, “each sequential”, or “concurrent”.Answer:1. 2 hour infusion of 1st chemo drug 96413 (initial) and 96415 (eachadditional hour)2. 1 hour infusion 2nd chemo drug 96417 (each sequential)3. 10 minute non-chemo IV push 96375 (each additional)4. IM injection 96372 (injection) modifier 59Reminder to check CCI for bundled codes that may need a modifier3010
Example # 2Patient presents for weekly chemo in a clinicbased infusion center, she receives: 50 minutei t iinfusionf i 1stt chemohddrugnd 2 hour, 45 minute infusion 2 chemo drug 3 separate non-chemo IV pushes ofdifferent substances31Example # 2Chose the initial code based on the reason for theencounter.Answer: 50 minute infusion 1st chemo drug 96413 (initial) 2 hours, 45 minutes infusion 2nd chemo drug 96417(each sequential) and 96415 x 2 (each additional) 3 separate non-chemo IV pushes of differentsubstances 96375 x 3 (each additional sequential)32Example # 3Dehydrated patient sent to the infusion suitein their physician’s office, he receives: Non-chemoNhIV pushh off an anti-emetictiti 2 hours of hydration infusion3311
Example # 3Chose the initial code based on the reason for theencounter.Answer: Non-chemo IV push 96375 (each additional) 2 hours hydration infusion 96360 x1 (initial) and96361 x 1 (each additional)34Services Bundled intoInfusion/Injection Services Any services leading up to the infusion or following theinfusion are included in the infusion administration andare not separately reportable. Use of local anesthesia IV start Access to indwelling IV, subcutaneous catheter or port Flush at conclusion of infusion Standard tubing, syringes and supplies Preparation of chemotherapy agents35Start and Stop Times3612
Start and Stop Times When reporting codes for which infusion time is afactor, use the actual time over which the infusion isadministered. ThThe infusioni f i titime iis calculatedl l t d ffrom ththe titime ththeadministration begins (the medication starts dripping)to when it ends (the medication stops dripping).CPT 2013 Professional Edition37Start and Stop Times Infusion codes are based on a time componentso it is necessary to document the time of eachdrug infused. The best way to document time is to record thestart and stop times of each drug administered.38Start and Stop TimesReminders: All “initial” infusion codes must be documentedas more than 15 minutes. The exception isinitial hydrationyinfusion, which must be morethan 30 minutes. “Each sequential” infusion codes must also bedocumented as more than 15 minutes All “each additional hour” codes must bedocumented as more than 30 minutes.3913
Start and Stop TimesExample:Drug A (Chemo):started 12:00 pmstopped 1:05 pmDrug B (Non-Chemo): started 1:35 pmstopped 1:45 pmCoding:Drug A - 1 hour, 5 minutes 96413 (chemo, initialinfusion)Drug B - 10 minutes 96375 (non-chemo, IV push, eachadditional)40Blood Draws, Phlebotomyand Port Flushes41Blood Draws, Phlebotomyand Port FlushesBlood Draws 36400-Venipuncture, younger than age 3 years, necessitating physician’sskill (separate procedure), for diagnostic or therapeutic purposes (not beused for routine venipuncture; femoral or jugular vein36405-””; scalp vein36406-””;3606 ; othero e veine36410-Venipuncture, age 3 years or older, necessitating physician’s skill, fordiagnostic or therapeutic purposes (not to be used for routine venipuncture)36415-Collection of venous blood by venipuncture36416-Collection of capillary blood specimen (e.g., finger, heel, ear stick)36420-Venipuncture, cutdown; younger that age 1 year36425-Venipuncture, cutdown; age 1 or over36591-Collection of blood specimen from a completely implantable venousaccess device (port)36592-Collection of blood specimen using established central or peripheralcatheter, venous, not otherwise specified (PICC line)4214
Blood Draws, Phlebotomyand Port FlushesBlood DrawsVenipuncture36415 - A needle is inserted into the skin over the vein to puncturethe blood vessel and withdraw blood for venous collection.The blood is used for diagnostic study and no catheter isplaced.This is the most common type of blood drawIngenix 2007 Coders’ Desk Reference-Procedures43Blood Draws, Phlebotomyand Port FlushesBlood Draws36591-Collection of blood specimen from a completelyimplantable venous access device (port)36592-Collection of blood specimen using established central orperipheral catheter, venous, not otherwise specified(PICC line)These services are bundled when reported with any otherservices performed the same day.44Blood Draws, Phlebotomyand Port FlushesBlood Draws There must be documentation of the blood draw If a patient is sent to an outside lab for the blooddraw and test, the venipuncture cannot be reported4515
Blood Draws, Phlebotomyand Port FlushesBlood DrawsExample: Chemotherapy patient presents for treatment. Patienthas an implantable venous port. Blood is drawn by thenurse through the port prior to chemochemo. Labs results arenormal and chemotherapy in administered. No blood draw code is appropriate because patient hadother infusion services performed that day. 36591(collection of blood specimen from a completelyimplantable venous access device) is bundled intoinfusion services.46Blood Draws, Phlebotomyand Port FlushesPhlebotomy 99195-Phlebotomy, therapeutic (separate procedure) “Code 99195 represents a therapeutic phlebotomy, oftenusedd iin ththe ttreatmenttt off polycytemial t i vera (ICD-9(ICD 9 coded238.41) to reduce the hematocrit and red blood cellmass. Therapeutic phlebotomies are used in thetreatment of other diseases as well.”AMA CPT 2013 Professional EditionCPT Assistant , June 1996, Volume 6, Issue 647Blood Draws, Phlebotomyand Port FlushesPhlebotomyExample: Patient with Polycythemiay yVera ((238.4)) ppresentsfor monthly therapeutic phlebotomy 99195-Phlebotomy, therapeutic4816
Blood Draws, Phlebotomyand Port FlushesPhlebotomy Services necessary to perform the phlebotomy (CPTcodes 36000, 36410, 96360-96376) are included inthe procedureprocedure.– 36000-IV start– 36410-Venipuncture, age 3 years or older, necessitatingphysician’s skill, for diagnostic or therapeutic purposes (not to beused for routine venipuncture)– 96360-96376-Hydration infusions and Therapeutic, prophylacticand diagnostic injections and infusions49Blood Draws, Phlebotomyand Port FlushesPort Flush 96523-Irrigation of implanted venous access device fordrug delivery systems (port) This code is only to reported when no other infusionservices are performed. If a port is flushed after aninfusion, the flush is bundled into the administration codeof the infusion and is not separately reportable.50Blood Draws, Phlebotomyand Port FlushesPort FlushPICC line flush/dressing change Currently there is no specific CPT codeA low level E/M, 99211, may be billable if: Meets Incident-to guidelines (if performed in a clinic setting) There must be an established plan of care from a physician(MD, ARNP, PA) Medically necessary Service is documented in the medical record If the patient is not seen the same day by the physician If no other infusion services are performed the same day5117
Evaluation and Management(E/M) Services with InfusionServices52E/M Service Performed the Same Dayas Infusion Services 99212-99215 - Established patient 99201-99205 - New patient 99241-99245 - Outpatient consultation E/M must be separately identifiable from the infusionservice Documentation must support the E/M visit and theinfusion service Modifier 25 is added to the E/M service53E/M Services E/M services must be deemed separatelyidentifiable and stand alone from theinfusion/injection services rendered thatday.day Separate diagnosis codes may not berequired, but can be a first line look forpayers for audit reasons (right or wrong).5418
E/M Service Performed the Same Dayas an Infusion ServiceThe exception to this is CPT code 99211 (levelone established patient visit)The drug and chemotherapy administration CPTcodes 96360-96375 and 96401-96425 includethe work and practice expenses of CPT code99211.55E/M Service Performed the Same Dayas an Infusion Service99211 may be appropriate for the following scenarios: Infusion pump disconnectPICC line flush/dressing changeChemo teachS lf administeredSelfd i i t dddrug tteachhOther teaching/instruction/counselingNursing visit requiring decision making**99211 can only be billed if the patient did not see a physician thesame day, if no infusion services were performed that day, ifincident-to guidelines are met (if performed in a clinic setting).56Incident to Guidelines Direct supervision in the office settingdoes not mean that the physician must bepresent in the same room with his or heraide However,aide.However the physician must bepresent in the office suite and immediatelyavailable to provide assistance anddirection throughout the time the aide isperforming services.5719
Incident to Guidelines See Medicare Manual Benefit PolicyS ti 100-02Section100 02 ChapterCh t 15 SectionS ti 6060.58Hydration Infusion59Hydration Infusion ClarificationBoth the “initial” and “each additional hour”hydration codes require more than 30 minutes ofinfusion time be documented in order to billservices. If time is less then 31 minutes-noservice is reported. 96360-initial, 31 minutes to one hour hydrationinfusion 96361- each additional hour, (31 minutes to one hour)hydration infusion6020
Hydration Infusion ClarificationPer CPT, the following services are included and are not reportedseparately with hydration codes:a. Use of local anesthesiab. IV startc. Access to indwelling IV, subcutaneous catheter or portd. Flush at conclusion of infusione. Standard tubing, syringes, and supplies61Hydration Infusion ClarificationHydration infusion services were developed toreport therapeutic intervention of hydration. Most common example is to treat dehydration Appropriate diagnosis should be assigned tohydration infusion services (276.51 dehydration)62Hydration Infusion ClarificationHydration infusion codes are NOT separately reportedwhen: Drugs are mixed with fluid and infused in the samebag/syringe A separate fluid bag is hung and run concurrently withanother drug infusion Fluid is used to flush the line(s) after a drug infusion Fluid is used to keep a line open in between infusions6321
Hydration Infusion ClarificationPer CCI hydr
The initial code should be the code that best describes the key or primary reason for the encounter The order in which 5 the encounter. The order in which infusions and injections occurs, does not effect which code is the initial. Chemotherapy vs. Non-Chemotherapy vs. Hydration Chemo
