Injections and Infusions Lamon Willis Determining the Hierarchy

Injections and Infusions Lamon Willis

Determining the Hierarchy

Determining the Hierarchy • Tier 1 – Type of Service • Chemotherapy • Therapeutic/prophylactic/diagnostic • Hydration • Tier 2 – Administration Route • Infusions (Therapeutic) • IV Pushes • Injections (SQ and IM)

Determining 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.

Determining 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?

Determining 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. ØThe hydration is reported secondary with 96361 x 3.

Infusions

IV 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

IV 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

IV 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)

IV 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

IV 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)

IV 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.

IV 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?

IV 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

IV 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

IV Infusion Therapy • 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)

IV Infusion Therapy • 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

IV 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

IV Infusion Therapy • 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.

IV 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

Chemotherapy Infusion

Chemotherapy 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

Chemotherapy 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)

IV Injections

IV 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)

IV 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.

IV 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.

IV Injections • Intra-arterial • 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.

IV 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.

IV 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

IV Push Examples • Patient given four IV pushes of Demerol, you would assign: • 96374 or 96375 depending on whethere were other drug administration services provided • and 96376 x 3 (provided there was 30 minutes or more between each push).

IV Push Examples • Patient given one IV push of Demerol and one IV push of Toradol – • Assign 96374 and 96375 (again depending on whethere was another initial service) • If another initial service was already reported, then assign 96375 x 2 since these are two different substances

IV Push Examples • Patient given one IV push of Demerol and one IV push of Toradol – • Assign 96374 and 96375 (again depending on whethere was another initial service) • If another initial service was already reported, then assign 96375 x 2 since these are two different substances

IM/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

Hydration Therapy • CPT defines hydrated based on the solutions (premixed, D 5 -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

Hydration 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

Hydration 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.

Documentation 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

Documentation 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

Documentation 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 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.

Documentation Resources • Admina. Star 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 “timeframe” should be clearly documented • Kansas Medicare—FAQ from December 2006: “. . . Documenting the actual times would carve out any noninfusion 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. ”

Start & 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.

Cross 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

Cross 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. ” ØThe original example in the 2012 CPT book was revised.

Case Scenario 1 • Patient comes to the ED on 02 -15 -15, and hydration is started at 10: 00 p. m. It continues until 6: 30 AM on 02 -16 -15. The patient received an IV push of morphine on 02/15/15 and again at 2 AM on 02/16/15. • What CPT codes and units should be reported?

Answer 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)

Case 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?

Answer • 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.

Case 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?

Answer • Oxaliplatin – chemotherapy 2 hours • 96413 (initial chemo infusion) x 1 • 96415 (each additional hour chemo infusion) x 1 • 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.

Case 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?

Answer • 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.

Case 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

Answer • 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