Injection and Infusion Coding Understanding the Basics Impact on ER’s, SDS, and OBS. Lynda Starbuck, MS, RHIA Vice President – Coding Services HCCS Home Town Health – August, 2012. Disclaimer.
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Lynda Starbuck, MS, RHIA
Vice President – Coding Services
Home Town Health – August, 2012
but we may finally see a new CPT Assistant in 2012 which is
dedicated to drug administration “difficult-to-code” issues
Outpatient Services only
CMS Covers if:
Covered Services for:
outpatient Evaluation and Management service is
performed, the appropriate E/M service (99201–99215,
99241–99245, 99354–99355) should be reported using
modifier -25 in addition to 96360–96549.
drug infused at the same time as another substance or drug.
reported once per day regardless of whether an additional
new drug or substance is administered concurrently
In transmittal 1702 dated March 13, 2009, CMS stated, “Drug administration services are to be reported with a line item date of service on the day they are provided. In addition, only one initial drug administration service is to be reported per vascular access site per encounter, including during an encounter where observation services span more than one calendar day.”
96360 would be reported once and 96361 twice. However, if instead of a
continuous infusion, a medication was given by intravenous push at 10
PM and 2 AM, as the service was not continuous, both administrations
would be reported as an initial service (96374). Hospitals should not
follow this per CMS and instead should continue to follow Medicare
Drug administration services are to be reported with a line-item date of
services on the day they are provided. … hospitals should report only one
initial drug admin service per encounter for each distinct vascular access
site … CMS has become aware of new CPT guidance regarding the
reporting of initial drug admin services in the event of a disruption in
service; however, Medicare contractors are to continue to follow the
guidance given in this manual.
substance on the same date of service, the initial code
should be selected. The second and subsequent infusion(s)
should be reported based on the individual time(s) of each
additional infusion(s) of the same drug/substance using the
appropriate add-on code.
receives one-hour intravenous infusions of the same antibiotic
every 8 hours on the same date of service through the same
IV access. The hierarchy for facility reporting permits the
reporting of 96365 for the first one-hour dose administered.
Add-on 96366 would be reported twice (once for the second
and third one-hour infusions of the same drug).
memorization” of the CPT hierarchy and rules
immersion of fluid through a vein or subcutaneously at a regulated rate, replacing or maintaining a fluid balance or adding medications or nutrients. (Hydration, IVPB)
direct introduction of a drug or other fluid into the bloodstream or body tissue. (IVP, IM, Subq)
- Drug pushed over 15 minutes, etc. is still a
(Ex: IV Ancef )
Bill Type Codes:
Shifting definitions of “integral” is difficult for everyone.
Transmittal A-01-13 issued November 20, 2001
Under OPPS packaged services are items and services that are considered to OPPS, be an integral part of another service that is paid under the OPPS… For example, routine supplies, anesthesia, recovery room and most drugs are considered to be an integral part of a surgical procedure so payment for these items is packaged into the APC payment for the surgical procedure.
Transmittal A-02-129 issued January 3, 2003
Certain drugs are so integral to a treatment or procedure that the treatment or procedure could not be performed without them.
4th Quarter 2007AHA HCPCS Coding Clinic
Although, the antibiotic infusion was specific to the patient and not part of the regular routine, the question remains whether or not the administration of the medication was due to the surgery. Therapeutic intravenous fluids, drug(s) or other substances administered that are integral to the procedure are not separately reported. Therefore, in this situation, the administration was prophylactic and would not be reported separately .
- CT scans with contrast
- CPT surgical procedures (including EKG’s)
- Foley catheters
Just because an edit appears that would allow modifier -59, does not mean you should just add it and just because an edit doesn’t surface does not automatically mean that what you are reporting is allowed!
–Unrelated to the presenting problem
–“Blown in” records
–Documentation by “exception”
–Procedures not documented
–Level of effort not demonstrated