DESK POLICY AND PROCEDURE FOR CODING OF INTRAVENOUS MEDICATIONS AND SUBSTANCES - Authored 3/1/08

PURPOSE:To ensure intravenous medications and substances administered in United General Hospital’s medical departments are consistently and accurately coded in compliance with Center for Medicare and Medicaid Services (CMS), hospital policy, third party payer policy, and best practices.

SUPPORTIVE DATA: CMS has established a hierarchy for the coding and billing of intravenous (IV) and intramuscular (IM) injections. Noridian Administrative Services (NAS) is the Fiscal Intermediary for CMS in WashingtonState. In that capacity, NAS guidelines state that infusions should be coded as primary to both IV pushes and IM injections with the exception of hydration infusions. Any “chemotherapeutic, therapeutic, prophylactic, or diagnostic service” should be coded as primary to hydration if it occurs during the same patient encounter.

DEFINITIONS:

Concurrent – drugs given at the same time

Sequential – drugs given one after another

Initial – first code used to identify drug administration – this is based upon

the highest administration level in the hierarchy listed below and not

necessarily on the chronological order of the infusions or injections

IV infusion – drug administration lasting greater than 15 minutes

IV push – drug administration lasting 15 minutes or less

IV hydration – fluid administration lasting greater than 30 minutes

Chemotherapy – administration of non-radionuclide, anti-neoplastic drugs,

monoclonal antibody agents, and other biologic response modifiers

PROCESS: Guidelines regarding drug administration have been provided by CMS, the American Health Information Management Association (AHIMA), Current Procedural Terminology (CPT) published by the AMA, and third party payers.

They include:

1)CMS has listed the hierarchy to be used when selecting the primary or initial service, as listed below in descending order:

  • Chemo initiation of prolonged infusion (>8 hours, requiring pump)
  • Chemo infusions
  • Chemo injections
  • Non-chemo infusions (>8 hours, requiring pump)
  • Non-chemo therapeutic infusions
  • Non-chemo therapeutic injections (IV pushes)
  • Hydration infusions
  • IM injections

2)The initial service is the code that best describes the key or primary reason for the encounter. For example, a patient who is receiving chemotherapy for a neoplasm would have the chemotherapy infusion coded first, then any subsequent infusions or IV pushes.

3)For the most part, there is only one “initial” service permitted. However, if IVs are administered in more that one body site or during a separate encounter on the same day, there may be two or more initial services.

4)Once the primary or initial services have been established, second or subsequent services are coded separately. Using the example in #1 previous, the hierarchy would be: 96417 (Chemotherapy Infusion), 96411 (Chemotherapy IV Push), 90767 (Other Infusion), 90775 (IV Push of New Drug), 90775 (IV Push of Another Different Substance), 90776 (IV Push of Same Drug/Substance), 90761 (Subsequent Hydration of greater than 31 minutes), and then 90772 (IM Administration).

5)Concurrent infusions occur when multiple infusions are provided simultaneously through the same IV line. As an example, 90765 (IV Infusion) would be used for the first hour of the administration of an antibiotic and 90768 (Concurrent Infusion) for the simultaneous infusion of another antibiotic. The first hour of an infusion must be 16 minutes or more.

6)If hydration is administered as the only IV service, it is coded 90760 (IV Infusion, Hydration, Initial 31 minutes to 1 hour). Additional hours of hydration must exceed 30 minutes in duration and are coded 90761 (IV Infusion, each additional hour). IV hydrations consist of pre-packaged fluid and/or electrolytes (normal saline, D5W, banana bags).

7)If a patient is seen in the Emergency Room, Outpatient, or Observation setting over a two-day period, the initial injection can be coded the first day with subsequent injections coded over the remainder of the stay. There is no longer a limit of eight hours for an infusion or hydration.

8)Fluids such as normal saline or Lactated Ringers when administered as a bolus can be coded to 90774 (Initial IV push) or 90775 (Subsequent IV push) when administered for a medical or therapeutic reason. It is not necessary that a diagnosis of dehydration be present.

9)Infusions should have a start and stop time documented in order to calculate how many hours to count and code. A start time MUST be documented; however, if the physician order or nursing documentation allows for calculation of a stop time, the facility may report the total infusion time. Medication records or nursing notes that include volume and cc/hour may be used to calculate the stop time.

10)Prolonged Infusions requiring a pump are coded with HCPCS code C8957 (Prolonged IV Infusion Requiring Pump).

11)Drug administration services that are integral to a procedure are not reported separately. Examples include drugs administered during anesthesia or conscious sedation, cardiopulmonary resuscitation, or during an operative episode.

12)Fluids administered to keep veins open (KVO) or as a vehicle for the administration of other drugs are not coded as hydration.

13)In order to code hydrations that have concurrent start or stop times with an infusion, there must be two separate IV sites. If the infusion ends, but hydration continues, the time can be counted and billed as long as it exceeds the minimum times for subsequent administration previously listed in #6.

14)Infusions that are started outside of the hospital may be reported for the time the patient was under the care of the facility. As an example, if the paramedics started an infusion of insulin in the ambulance, the time the infusion continued to run while the patient was in the Emergency Room can be counted.

15)Subcutaneous or intramuscular injections are considered a component of an infusion and will require a modifier 59 if administered separately.

16)Irrigations of an implanted venous access device or PICC line are not reported if an IV push or infusion is provided on the same day. However, if the patient is seen specifically for a flush, code 96523 can be applied.

17)If performed to facilitate an infusion or injection, the following services are included and are not reported separately:

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

REFERENCES:

CPT Assistant November 2205

CPT Assistant May 2007, Volume 17, Issue 5

CPT Assistant June 2007, Volume 17, Issue 6

CPT Assistant September 2007, Volume 17, Issue 9

Medicare A News Issue 2054 July 26 2006

Medicare A News Issue 2063 September 19 2007

Medicare LCD 26046

APCs Weekly Monitor, Volume 7, No. 48, December 8 2006

APCs Weekly Monitor, Volume 8, No. 4, January 26 2007

APCs Weekly Monitor, Volume 8, No. 8, February 23 2007

APCs Weekly Monitor, October 26 2007

APCs Weekly Monitor, January 18 2008

Judy Lunceford, CDMSG Consultant

CMS Injections and Infusion Administration Codes for Chemotherapy and Non-

Chemotherapy Drugs, Rev. January 2006

CMS Article Revision on IV Infusion Documentation, May 16 2007

AMA Comments and Questions

Briefings on APCs, November 2006

AHIMA Audio Seminar, Coding Injections and Infusions, January 31 2008

NAS Clarification on Billing for Hydration Infusions, February 1 2008