Current Procedure Terminology or CPT® is the registered trademark of the American Medical Association (AMA). The codes in CPT are 5-characters in length, with over 10,300 Category I, II and III codes, Category I covers the Evaluation and Management visits, Anesthesia, Surgery, Radiology, Pathology and Laboratory, and the Medicine Section codes. It is within the Medicine and Procedure Section (range 90281 to 99607) that you find the codes to capture the administration via injection and infusion services.

Injection and Infusion (I&I) services are a common area for Auditors to review as there continues to be mistakes and errors with the code assignment. There can be issues with I&I coding due to lack of documentation for “start and time times”, lack of medical necessity documentation for hydration services, not following the CPT hierarchy for their specific codes and just “confusion” regarding the CPT rules.

Clinical documentation could be at the center of errors found during an audit.  Even with an EHR (Electronic Health Record), the features, functions and keystrokes can result in the wrong information and thus wrong code selection. Education to the clinical staff is important, i.e., Nursing and Physicians.

Here are a  few tips for the CPT coding of injections and infusions, this is not all inclusive:

  • Services leading up to the infusion or following the infusion are included in the infusion administration and are not separately reportable. (see the list below)
    • Use of local anesthesia
    •  IV start
    • Access to indwelling IV, subcutaneous catheter or port
    • Flush at conclusion of infusion
    • Standard tubing, syringes, and supplies
    •  Preparation of chemotherapy agents
  • Physicians: report the initial service that best describes the primary encounter reason
  • For all infusions reported by the facility (hospital outpatient), IV pushes and injections are coded based on a hierarchy.
  • The hierarchy determines which infusion service will be coded as the “initial”.
    • Utilize the CPT I&I hierarchy (Chemotherapy is the highest and Hydration is the lowest service in the hierarchy – see the CPT codebook)
      • Chemotherapy services are primary to therapeutic, prophylactic, and diagnostic services
      • Therapeutic, prophylactic, and diagnostic services are primary to hydration services
  • The hierarchy does not apply to subcutaneous or intramuscular injection
  • Hydration is defined as the replacement of necessary fluids via an IV infusion which consists of pre-packaged fluid and electrolytes. Documenting the medical necessity for hydration is important
  • Concurrent hydration is not codable/ billable via a HCPCS code and not separately payable
  • Use the “Current Infusion” CPT code when two substances/drugs in two separate bags/syringes are infused at the same time through one access
  • The infusion time is calculated from the time the administration begins (the medication starts dripping) to when it ends (the medication stops dripping).

The  CPT coding of injection and/or infusion services can be challenging, so attention to detail really matters. In addition, experience with outpatient CPT I&I coding and ongoing education following coding audits can enhance accuracy.

There are a few questions to ask about the outpatient service area that provides injections and/or infusions are:

  • When was your last coding audit of Injection and Infusion services?
  • What were the findings from that coding audit?
  • Is the clinical staff aware of the documentation required to support the service (CPT code)?

Auditing and monitoring should be a regular part of one’s compliance program.  It is springtime and that is a great time to have a CPT I&I coding audit conducted!

Written by Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA Approved ICD-10-CM/PCS Trainer

Reimbursement Management Consultants (RMC) can provide assistance with medical coding support, auditing, education, compliance consulting, and HCC/risk adjustment services. RMC is a woman-owned, US-based and operated company which specializes in a variety of medical coding and auditing services. Contact us here.