Injection/Infusion Guidelines

Injection/Infusion/Hydration CPT Coding - Guidelines

Ø  Coding guidelines for IV infusion, IV injection (IV push) are complex

Ø  Must follow AMA CPT® coding guidelines

Ø  Documentation of start and stop times, mode/route of administration, location of line and line flushes

Primary/Initial Service: hierarchy

§  Chemotherapy infusion

§  Chemotherapy injection (push)

§  Therapeutic/prophylactic/diagnostic infusion

§  Therapeutic/prophylactic/diagnostic injection (push)

§  Hydration

Ø  Only one initial code for each IV line for each episode of care

Ø  Additional Sequential Service

§  Administered in sequence (one after the other)

§  Line flush may or may not occur between drugs

§  Secondary or subsequent service to the initial service

§  Report once per sequential infusion of same “infusate mix”

Ø  Concurrent Infusion

§  Multiple drugs running at the same time through the same line, different bags

§  Billable only once per encounter regardless of the number of drugs infused

Ø  SQ/IM Injection/Vaccine

§  Does not affect distinction between primary and secondary

§  Report as many times as ordered and Administered

Ø  Hydration

§  Do not report hydration less than 30 minutes

§  Do not report hydration used only to facilitate administration of another drug

§  Do not report KVO, line flush, heplock

§  Must be an order for the solution

§  CPT® defined solutions – normal saline, lactated ringers, D5W, premixed electrolytes

§  Start and stop times are essential

§  Calculation nuances for hydration versus infusion

§  Initial Hydration time must be 31minutes

“31 minutes to 1 hour” = 31 – 90 minutes

§  Initial Infusion must be greater than 15 minutes

“up to 1 hour” = 16 – 90 minutes

§  Each additional hour (hydration or infusion) – may report multiple units

“more than 30 minutes beyond 1 hour increments”

= 91 – 150 (1 additional hour)

= 151 – 210 (2 additional hours) etc.

Ø  The History:

ED patient presents to a small community hospital with multiple medical problems, including possible CVA, pneumonia, sepsis and septic shock, skin ulcer, R foot. After stabilization, patient is transferred to regional medical center for further specialty care.

Medication Record:

Additional Nursing Notes:

1430 #18 IV placed L hand

1520 – B/P 71/51 HR 96, reported to PA.

NS 500 ml bolus began, sterile dressing applied to R lower extremity

1630 – SC #20 to L FA

1645 Dopamine 5meq kg/min

1715 Dopamine (down arrow) 2.5 meq kg/min

1558 saline bolus complete. IV @100 ml/hr

1815 NS 500 ml bolus began

2000 EMS here to transfer pt via stretcher. Vancomycin infusing without difficulty.

Ø  Good medication form – includes start and stop times, fluids hung, IV rate, IV volume infused, and initials of provider

Ø  Medication record does not specify location of IV line

Ø  From nurses notes we know IV place in left hand at 1430

Ø  From nurses notes we know a second line was started in the left forearm at 1630

Ø  Dopamine start time documented at 1645per nursing notes, start time 1700 per medication record – conflicting

Ø  We know that clinically, Dopamine drip and antibiotic would not be infused in the same Line

Ø  If coder is to accurately assign drug administration codes, must make assumptions or clarify documentation, and coders cannot assume!

Ø  Illegibility and wide use of abbreviations

Ø  Patient transferred at 2000

(assumes clarification of documentation of multiple lines)

Therapeutic infusions – Line 1:

Rocephin 1625–1715 (50 min) = 96365 (initial service, up to 1 hr)

Zithromax 1715-1830 (75 min) = 96367 (sequential, up to 1 hr)

Vancomycin 1930-2000 (30 min) = 96367 (sequential, up to 1 hr)

Therapeutic infusions – Line 2:

Dopamine drip in D5W 1700-2000 (180 min) = 96365-59; 96366 x2

(initial service, separate line, separate drug)

Hydration infusions:

NS bolus then 100ml/hr 1525-1558; NS 100 ml/hr 1558-2000

Must carve out 1625-1830 and 1930-2000 for drug delivery

Leaving 1525-1625 (60 minutes) and 1830-1930 (60 minutes) = 96361

(secondary/subsequent service, 120 minutes)