Infuse Yourself with Coding Knowledge

Tips and tricks for proper drug administration coding.

by Amy Lee Smith, MBA, CPC, CPC-H, CPMA, CIA, CRMA

If the profuse number of Office of Inspector General (OIG) audits showing improper payments for drug claims submitted to Medicare every year is any indication, it’s safe to say that drug administration coding can get sticky. Proper drug administration coding requires as much precision as the services themselves. Just like clinicians learn little tricks for properly injecting drugs, however, there are several tips and tricks you can use to pick the right code every time.

Drug Administration Basics

First, remember that there are three categories of drug administration:

• Hydration: CPT® codes 96360-96361 are for pre-packaged fluids and electrolytes. These codes are not used to report infusion of drugs or other substances and are not reported by the physician in a facility setting.
• Therapeutic/Prophylactic/Diagnostic: See Table 1 for CPT® codes to report for the administration of drugs and other substances (other than hydration). Do not report these codes for chemotherapy or other highly complex drugs/biological or when fluids are used to administer the drug(s); the fluid administration is incidental hydration and is not separately reportable. These codes are not reported by the physician in a facility setting.
• Chemotherapy or other biologic agents/complex drugs: See Table 2 on the next page for appropriate CPT® codes. “Chemo” includes other highly complex drugs or biologic agents such as:
  • Non-radionuclide anti-neoplastic drugs
  • Anti-neoplastic agents provided for treatment of non-cancer diagnoses
  • Certain monoclonal antibody agents
  • Other biologic response modifiers

Use of these codes typically requires advanced practice training and competency; special considerations for preparation, dosage, or disposal; and usually entails significant patient risk and frequent monitoring far beyond that of therapeutic administrations. Physicians in the facility setting may not use chemotherapy codes.

Report separate codes for each method of administration when chemotherapy is administered by different techniques. Medications administered independently as supportive management of chemotherapy are reported separately using 96360, 96361, 96365, or 96379, as appropriate.

Along with three categories of drug administration, there are three methods by which drugs may be administered:

• Injection: Do not use CPT® 96372 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular for the administration of vaccines/toxoids. This code does not include injections for allergen immunotherapy. Although hospitals may report injection codes when the physician is not present, physician offices may not. You may use injection codes to report non-antineoplastic hormonal therapy.
• IV Push: CPT® 96374 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug is appropriate when intravenous (IV) push is the primary service. Add-on code +96375 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure) may be reported with 96365, 96374, 96409, or 96413 to identify an IV push of a new drug when provided as a secondary service after a different initial service is administered through the same IV access.

Add-on code +96376 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility drug (List separately in addition to code for primary procedure) is used only when the same drug is administered twice in one encounter, but not within 30 minutes of each other. All of these IV push codes are reported for facilities only, and may be used for infusions lasting 15 minutes or less.

Infusion: Refer to Table 1 on the preceding page for infusion codes and their instructions.

What makes your job so sticky is that these categories and methods can be combined in a number of different ways, all of which are coded differently.

Determine the “Initial” Service

The American Medical Association (AMA) created different codes for “initial” and “subsequent” administrations; coding guidelines state there should be only one initial code per encounter, unless two separate access sites are required. So how do you determine what the initial service is when more than one method or category of administration is provided?

Although the rules vary depending on where the service is provided, the actual chronological order of administration is not important for coding. The initial code is not necessarily the first service provided.

In the physician practice, the initial service is the primary reason for the visit. For example, a patient comes in for chemotherapy, but also gets an antibiotic injection and a hydration infusion to supplement the chemotherapy. The primary reason for the visit is the chemotherapy so it is the initial service.

In the outpatient facility setting, there is a hierarchy to determine the initial service:

1.  Chemotherapy infusions

2.  Chemotherapy IV pushes

3.  Chemotherapy injections

4.  Therapeutic/Prophylactic/Diagnostic infusions

5.  Therapeutic/Prophylactic/Diagnostic IV pushes

6.  Therapeutic /Prophylactic/Diagnostic injections

7.  Hydration

The highest-ranking service provided is considered the initial service. For example, a patient comes into a hospital outpatient department for an antibiotic injection, but also receives a hydration infusion. The initial service is the antibiotic injection because the therapeutic injection ranks higher in the hierarchy than the hydration infusion.

Coding for Multiple Administrations

If you can bill only one initial code per patient, per date of service, per IV access site, how do you capture the work when more than one administration is provided during a single encounter?

Specific codes for sequential, subsequent, and concurrent administrations account for additional services provided. Use subsequent or concurrent codes where appropriate, regardless of the administration order (e.g., first IV push given subsequent to an initial one-hour infusion is reported using a subsequent IV push code). Before you make your code selection, it’s important to know time requirements and documentation rules.

Time Requirements

One of the biggest obstacles when coding drug administration is the common lack of documentation; start and stop times must be clearly and completely documented in the medical record by the clinician. The start time is normally well documented, but the stop time is quite often omitted. Check with your payer to see their requirements for these situations; some will accept a code for an IV push even if a stop time is not documented, while others will not.

In general, an IV push code may be used for an infusion lasting 15 minutes or less (again, check with your payers for clarification). In drug administration terms, “one hour” means any infusion lasting between 16 and 90 minutes. Only when an infusion lasts longer than 90 minutes can you code the “additional hour” code. “Each additional hour” means increments greater than 30 minutes over the initial hour. Do not include time spent keeping veins open (see Table 3 for examples).

Table 1: Diagnostic/Therapeutic/Prophylactic Infusion Codes

Table 2: CPT^® codes for chemotherapy administration

Table 3: Reporting infusion time

Know What’s Included

The following services are included in all of the drug administration codes, and are not separately reportable:

• Use of local anesthesia
• IV start
• Access to indwelling IV, subcutaneous catheter, or port
• Flush at the conclusion of infusion
• Standard tubing, syringes, and supplies

Chemotherapy administration codes also include preparation of drugs/agents and any fluids used to administer the chemotherapy.

Other Considerations

If a significant, separately identifiable evaluation and management (E/M) service is provided, report the appropriate E/M code with modifier 25 in addition to the infusion codes. A different diagnosis is not required; however, you cannot report 99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services with infusion codes.

If multiple infusions are administered, report only one initial service code, unless two separate IV sites are required.

• Per the Medicare Claims Processing Manual (chapter 4, section 230.2) as of 2007, only one initial service code can be reported per patient, per date of service, per separate IV access site.
• If there are multiple IV access sites, each site may be coded with an initial code and modifier(s), as appropriate, and must be supported by documentation in the record indicating it is medically reasonable and necessary for the drug or substance administrations to occur at separate intravenous access sites.

February 1st, 2013

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Eliminate INFUSION Confusion

Proper coding of drug administrations in non-facility settings starts with good documentation.

By Maryann C. Palmeter, CPC, CENTC

For infusion/injection administration, “good” documentation begins with a physician’s order that provides the name of the drug, dosage, and reason for its administration. From a best practice perspective, documentation also should include a record that lists the drug source, lot number, expiration date, and patient on whom the drug was administered. How each substance was administered (route) and the site of each administration also must be documented.

The time each substance was administered also should be included in the documentation to properly sequence multiple administrations. CPT® and Medicare do not specifically require start and stop times for drug infusions, but documenting these times will save the coder the need to calculate infusion time based on volume, rate, and intravenous (IV) calibration. Coders must not assume infusion time based on a physician’s order alone because there is always the possibility that the infusion had to be stopped or discontinued. Also, the physician’s order may not take into account IV calibration.

Know the What, How, Where, When, and Why

Coding for the administration of injections and infusions requires you to know five key pieces of information:

1. What – Tells the substance/drug/agent administered so you can select the proper subheading (e.g., hydration, therapeutic, chemotherapy) for the administration.
2. How – Tells by which route the substance entered the bloodstream (e.g., intra-arterially, subcutaneously, via IV infusion, etc.), and helps to further define code selection.
3. Where – Tells the site injected (e.g., right deltoid) or where the IV line was placed (e.g., left hand). This also helps with modifier application and coding of multiple administrations.
4. When – Tells us at what time each substance was administered and total infusion time. This helps with code selection, unit selection, and sequencing.
5. Why – Supports medical necessity and helps with sequencing (i.e., the primary reason for the encounter).

Look at What Is Bundled and What Isn’t

Services performed to facilitate the infusion or injection—such as the use of local anesthesia, IV start; access to an indwelling IV, subcutaneous catheter or port; flush at conclusion of infusion; and standard tubing, syringes, and supplies—are not to be reported separately.

If the physician practice purchased the drugs/substances, the corresponding HCPCS Level II codes may be reported in addition to the administration codes.

Per CPT®, if a significant, separately identifiable evaluation and management (E/M) service is performed it may be reported in addition to the administration codes. Some private payers have rules that contradict CPT®, however, so be sure to research specific payer contracts and policies.

For Hydration See CPT^® 96360-96361

Hydration is administered only by IV infusion and is used to report the administration of prepackaged fluids and electrolytes (e.g., normal saline, D5W), not drugs or other substances. A minimum of 31 minutes is required to report the first hour of hydration.

Hydration is bundled when performed concurrently with other infusion services; however, hydration may be reported if provided secondary or subsequent to a different initial service administered through the same IV access. Hydration may also be billed separately if provided prior to the primary substance. (See definition of Sequential in the accompanying Key Definitions sidebar.)

Consider Therapeutic, Prophylactic, and Diagnostic Infusions/Injections Key Points

There are some key points to consider regarding therapeutic, prophylactic, and diagnostic infusions/injections (CPT® 96365-96379). For example, codes describing these procedures are not used for:

• hydration or vaccines/toxoids
• allergen immunotherapy
• antineoplastic hormonal or nonhormonal therapy
• hormonal therapy that is not antineoplastic
• chemotherapy
• highly complex drugs
• highly complex biologic agents
• therapeutic, prophylactic, and diagnostic infusions/injections, which require direct physician supervision for patient assessment, provision of consent, safety oversight, and intra-service staff supervision

Do not report 96372 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular injection if the substance was administered without direct physician supervision. You might instead refer to 99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician … Note, however, that Medicare also requires direct physician supervision to bill 99211. If the physician does not provide direct supervision, neither 96372 nor 99211 may be billed to Medicare. If the administration code cannot be billed, neither can the drug/substance administered.

Infusions require:

• special consideration to prepare, dose, or dispose of;
• practice training and competency for the staff who administer them; and
• periodic patient assessment with vital sign monitoring.

Apply Chemotherapy and Other Highly Complex Drugs or Biologic Agents Rules

CPT® 96401-96549 apply to parenteral administration of nonradionuclide antineoplastic drugs, antineoplastic agents provided for treatment of noncancer diagnoses, substances such as certain monoclonal antibody agents, and hormonal antineoplastics.

Per CPT®, because of the complex nature of the drugs involved, the administration requires advanced practice training and competency for staff who provide them, and special consideration for preparation, dosage or disposal. Physician work and/or clinical staff monitoring of the patient goes well beyond that of therapeutic drug agents because there is a greater risk of severe, adverse patient reactions. Do not report preparation of the chemotherapy/complex drug/biologic agents when performed to facilitate the infusion or injection.

Direct physician supervision is required for patient assessment, provision of consent, safety oversight, and intra-service supervision of staff.

Report each parenteral method of administration employed when chemotherapy/complex drug/biologic agents are administered by different techniques. When independent or sequential administrations of medications are administered as supportive management, report in addition to chemo/complex/biologic agent codes. CPT® does not include a code for concurrent chemotherapeutic infusion because chemotherapeutics are not usually infused concurrently. If a concurrent chemotherapy infusion were to occur, CPT® instructs us to use the unlisted chemotherapy procedure code 96549 Unlisted chemotherapy procedure.

Example: A patient presents for chemo treatment. He is provided an antiemetic to help with anticipated nausea, and is also given a B12 injection for anemia. IV infusion of antiemetic drug X in left arm, start 14:50/end 15:25. IV infusion chemo drug A same site, start 15:30/end 16:45. At 16:55 patient receives B12 injection IM in right hip (ventrogluteal). Physician provides direct supervision.

• Start with the primary reason for the encounter (patient presents for chemo treatment, sequence accordingly).
• Code IV chemo infusion as the primary service.

Code IV chemo infusion based on time for single substance/drug (96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug) for up to one hour. Total infusion time was one hour and 15 minutes. Per CPT®, do not report the additional hour code 96415 Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure) unless the infusion interval is greater than 30 minutes beyond the hour increments. In this case, the infusion interval after the initial hour was only 15 minutes so you would not report 96415.

• Follow with IV infusion of prophylactic antiemetic drug X.

Report 96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion, up to 1 hour (list separately in addition to code for primary procedure) because the infusion was provided subsequent to the chemo service and was administered through the same IV site. Remember, if injection or infusion is subsequent or concurrent in nature, even if it is the first such service within that group of services, report the subsequent or concurrent code from the appropriate section.

• End with therapeutic injection of B12 administered intramuscularly by coding 96372 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); substance or intramuscular (physician provided direct supervision).
  • Correct coding is: 96413 x 1, 96367 x 1, 96372 x 1.
  • Don’t forget to include the HCPCS Level II codes for the drugs administered.

Understand Correct Sequencing

For physician billing in a non-facility setting, report as the “initial” service the code that best describes the key or primary reason for the encounter, irrespective of the order in which the infusions or injections occur. This is different than for facility settings where sequencing rules require administrations to be coded in the following order:

• Chemotherapy/Complex
• Therapeutic, prophylactic, diagnostic
• Hydration

For facility billing, infusions are coded before pushes and pushes are coded before injections.

Example: Patient presented for chemo treatment. IV infusion of chemo drug C, start 09:00/end 11:00. Piggyback infusion of Tx drug D, start 09:45/end 10:45. Prophylactic drugs A and B mixed together and administered via IV infusion prior to chemotherapy, start 7:55/end 8:55. All infusions are via same site and the physician provided direct supervision.

• Start with the primary reason for the encounter (patient presents for chemo treatment, sequence accordingly).
• Code 96413 x 1 for the first hour of infusion chemo drug C.
• Code 96415 x 1 for the second hour of infusion chemo drug C.
• Code 96367 x 1 for one hour infusion of pro drugs A & B mixed together.

Count drugs mixed together as one infusion; and code them as sequential even though they were administered prior to the chemo. Per CPT® Assistant, when administering multiple infusions, injections, or combinations, only one “initial” service code should be reported, unless administration occurred through separate IV sites—even if subsequent or concurrent in nature and even if it is the first such service within that group of services. Although this is the first prophylactic infusion, it would be coded as subsequent because chemo drug C is coded first per physician sequencing rules. Remember: Subsequent can mean administered before or after the initial drug.

• Code 96368 x 1 for one-hour concurrent infusion of Tx drug D (note Piggyback).
• Correct coding is: 96413 x 1, 96415 x 1, 96367 x 1, 96368 x 1.
• Don’t forget to include the HCPCS Level II codes for the drugs administered.

Multiple Administrations

If the injection or infusion is subsequent or concurrent in nature, even if it is the first such service within that group of services, report the subsequent or concurrent code from the appropriate section. More than one initial service code is only appropriate when there are separate IV sites (e.g., IV right hand and IV left hand) or separate encounters (e.g., visit at 8 a.m. and separate encounter at 3 p.m. on the same day).

Append modifier 59 Distinct procedural service to identify the distinct procedural service when more than one initial service code is justified. Some payers may accept RT Right side and LT Left side modifiers, instead of modifier 59, to signify separate sides of the body.

Example encounter 1: Cancer patient receives IV infusion of antineoplastic drug, start 08:05/end 11:10.

Example encounter 2, same day: Patient returns for administration of hydrating solution provided via IV infusion for dehydration, start 14:20/end 16:30. New line started.

• Code 96413 for the first hour of IV infusion of the chemo drug (antineoplastic drugs are coded under chemo/complex/biologic agent subheading).
• Code 96415 for each additional hour.

There were two additional hours beyond the first hour so, two units are reported.

• The patient returned during a different encounter: Because new IV access had to be established to infuse the hydration solution, select code 96360 Intravenous infusion, hydration; initial, 31 minutes to 1 hour for IV infusion, hydration; initial for the first hour.
• Code 96361 x 1 for the additional hour of hydration.

According to CPT® instructional notes, if the hydration solution had been administered through the same IV access as a secondary or subsequent service to the chemo infusion, we would have coded ALL of the time for hydration with code 96361 Intravenous infusion, hydration; each additional hour (list separately in addition to code for primary procedure) instead of splitting out into initial and additional codes. The key here is different IV access. Because the patient returned and a new IV access had to be established, start with the initial hydration code and code any additional hours with add-on code 96361.

• Append modifier 59 to identify the hydration service codes as distinct, procedural services because the hydration was performed during a separate encounter.
• Proper coding for both encounters is: 96413 x 1, 96415 x 2, 96360-59 x 1, 96361-59 x 1
• Don’t forget the HCPCS Level II codes for the drugs.

To code administrations properly, it is important to understand these key terms.

Push – Also known as a bolus, is medication administration from a syringe directly into an ongoing IV or intra-arterial infusion or saline lock. Per CPT^®, if a health care professional administers a substance/drug intravenously or intra-arterially, and is continuously present to administer and observe the patient, the administration is treated as a push. Continuous presence must be documented. If the infusion time is 15 minutes or less, the administration is treated as a push.

Concurrent – Multiple drugs or substances infused simultaneously through the same line. Multiple substances mixed in one bag are considered one infusion, not a concurrent infusion.

Piggyback – Infusion of medication given on top of the main solution that allows for the intermittent infusion of different medications at specific times. See also Concurrent.

Sequential – Initiation of different fluid or drug administered immediately following the primary substance. It may also be referred to as secondary. Note: Sequential can also refer to drugs/substances administered before the primary substance.

July 1st, 2011

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CCI v.15.2 Corrects Bundling Error

The July update to the Correct Coding Initiative (CCI) corrects a bundling error discovered in the April update, reports Coding News.

A bundling error in version 15.1 applied CPT® code 64550 Application of surface [transcutaneous] neurostimulator into hundreds of other procedures. Version 15.2, effective July 1, only bundles 64550 into several anesthesia codes.

Also in version 15.2 you will find bundled into most of the radiology codes and some of the echocardiography codes add-on code 96376 Therapeutic, prophylactic, or diagnostic injection; each additional sequential intravenous push of the same substance/drug provided in a facility.

CCI 15.2 contains six mutually exclusive edits bundling general eye service codes 92002 Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, new patient, 92012 Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits, and 92014 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient into special eye service codes 92018 Ophthalmological examination and evaluation, under general anesthesia, with or without manipulation of globe for passive range of motion or other manipulation to facilitate diagnostic examination; complete and 92019 Ophthalmological examination and evaluation, under general anesthesia, with or without manipulation of globe for passive range of motion or other manipulation to facilitate diagnostic examination; limited. You cannot use a modifier to separate these codes.

You can, however, use a modifier to separate 92018 and 92019 from their bundling with most eye surgery codes.

For more information, read “CCI 15.2 Retracts Neurostimulator Edits From 15.1” on the Coding News Web site (registration required).

July 13th, 2009

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