Coding for the administration of injections and infusions involves many challenges due to extensive CPT instructional notes, hierarchy rules, and differing payer guidelines. Outsourced medical billing can ease the confusion around reporting drug administration services. Here are 7 tips to overcome common challenges in this area.
- Understand the terms: Current Procedural Terminology (CPT) defines the terms “injection” and “infusion” as follows:
- Injection-delivers a dosage in one “shot,” rather than over a period of time; may be administered by various routes, including subcutaneous, intramuscular, intraarterial, and intravenous
An injection is medication administered for an immediate effect (typically within 3-5 minutes) is an injection.
- Infusion-administration of intravenous fluids and/or drugs over a period of time for diagnostic or therapeutic purposes
An infusion is a medication or solution that is administered via saline or other solutions and given over a period of time (usually 30 minutes or more).
- Understand the basic hierarchies: Hierarchies make infusion billing complex. There are hierarchies for medication type and route of administration.
- Medication type/service level:
- Chemotherapy or other biologic agents/complex drugs – Chemo includes highly complex drugs or biologic agents
- Hydration – re-packaged fluids and electrolytes
- Therapeutic, prophylactic and diagnostic substance – administration of drugs and other substances (other than hydration)
- Medication type/service level:
- Infusion categories and route : Infusions differ based on route and method of administration. The three broad types of infusion/injection services that practices provide are:
- Intravenous Infusions (IV) – Administration within or into a vein or veins.
- Intravenous Pushes (IVP) – This involves rapid intravenous injection (push) using a syringe. It is usually given over a period of less than 15 minutes without the aid of an electronic or manual external pump.
- Injections (Sub-Q, IM) – The Sub-Q injection involves using a short needle to injecta drug into the tissue layer between the skin and the muscle. The IM injection is direct injection of a medication into the muscle of a patient.
There are multiple codes for IV push and the code selected would be based on whether the push is initial or not as well as the time that passes between multiple pushes of the same non-chemotherapeutic substance or drug. Hydration services and therapeutic infusions (chemotherapy and non-chemotherapy) have their own distinct coding rules.
- Know the time criteria: Time must be documented correctly in the medical record to assign the codes for infusion/injection administration services. Documentation must specify at what time each substance was administered and total infusion time. The infusion time is the actual time over which the infusion is administered. Best practice is to document Start and Stop times for all drugs/substances. Time is always billed by the hour. For the first hour, the infusion must be at least 16 minutes (greater 15mins) to meet the requirements for the first hour of infusion. Anything less than 16 minutes is regarded an Intravenous Push (IVP).
- Initial, Sequential/Subsequent, or Concurrent: It must be specified is a drug or substance administered is Initial, Sequential/Subsequent, or Concurrent.
- Initial: To code initial administration, hierarchy must be utilized. Only one initial code is used per encounter
- Sequential/Subsequent: This refers to the infusion of a different drug than primary. It must be given prior to or after other drugs (not considered concurrent).
- Concurrent: This refers to infusions of new substances or drugs at the same time as another substance or drug. Concurrent service is only allowed once per encounter.
In the physician practice, the initial service is the primary reason for the visit. AAPC provides the following example to illustrate this: a patient who comes in for chemotherapy also gets an antibiotic injection and a hydration infusion. The chemotherapy is the initial service as it is the primary reason for the visit. In the outpatient facility setting, the initial service is determined based on its ranking in the hierarchy levels. Chemotherapy is has the topmost rank, followed by non-chemotherapy agents and hydration.
- Ensure compliance: AHIMA points out that audits by governmental agencies and third-party payers increasingly focus on units of service reporting in injection and infusion coding. Proper knowledge of the National Correct Coding Initiative edits and injection and infusion coding can help avoid negative audit results. AHIMA provides various tips to mitigate compliance concerns such as adhering to CPT coding rules, thorough documentation, resolving edits, periodical internal and external audits, etc.
- Know the current CPT codes: The 2019 CPT codes for injections and infusions are as follows:
- Hydration 96360 ‐ 96361
- Therapeutic, Prophylactic, Diagnostic 96365 – 96379
- Chemotherapy (Anti‐neoplastic agents, Biological response modifiers, Monoclonal antibodies) 96401 ‐ 96549
Coders should also be knowledgeable about modifier use.
- Ensure comprehensive documentation: Documentation to report infusion/injection administration requires the following elements:
- Detailed Physician Order including: Medical condition necessitating the medication ordered, medical condition necessitating the need for hydration (if ordered), name of drug, dosage, length and route of administration, and frequency of administration
- Medication Administration Record
- Nursing documentation
Selection of injection and infusion codes is a demanding aspect of outpatient coding. In addition to being knowledgeable about various terms, a thorough understanding of guidelines provided by the American Medical Association (AMA) is necessary for accurate coding. Outsourced medical billing companies have AAPC-certified coders who are knowledgeable about the nuances of reporting infusion/injection services. Partnering with an experienced company can ensure success with coding and prevent denials.