Certain elements of documentation must be present to code infusions, injections, and hydrations properly. An order by the physician, which must be dated, timed, and signed with the name of the drug, the dose and the route of administration should be on file for services performed. Infusion services require direct supervision by medical staff. The coder should next ask a series of questions to ensure services are coded correctly, which include:
- Who are you coding for, facility or physician?
- Was the service initial, subsequent, concurrent, or prolonged?
- What was the location of the administration (i.e. intramuscular, intravenous…?)
- Are start and stop times documented?
- Were other services performed which may be coded separately?
There are separate coding rules for physician billing and facility billing. Coding for a facility is based on the hierarchy system. This information is included in the guidelines preceding the administration codes in the CPT book:
- Chemotherapy (Infusions primary to pushes which are primary to injections)
- Therapeutic (nonchemo) (Infusions primary to pushes which are primary to injections)
- Hydration administration
For physician coding, the initial code that best describes the key or primary reason for the encounter, irrespective of the order in which the infusion or injection occurs should be reported as the initial code. Physician coding DOES NOT use the hierarchy system.
Now, let’s talk about the classification of services. An initial service is the first of a series or service. An initial service is reimbursed at a higher rate due to the extra services that are performed. Next, a sequential service is performed one right after another, in a series, when a new drug or substance is administered. A concurrent service is performed at the same time as another service. A prolonged service is extended in duration or length.
Nursing documentation should include the route of administration. Was the drug or substance administered intramuscularly, subcutaneously, via IV push, or infusion? The site or location of the administration should also be documented. It is also critical that the start and stop times are documented for services to be coded properly.
There are other services typically performed with infusions, injections and hydrations and are included in the administration coding. These services should NOT be reported separately: use of local anesthetic, IV start, access to indwelling IV, subcutaneous catheter, or port, flush at the conclusion of the infusion, standard tubing, syringes, and supplies, and preparation of chemotherapy agents. A coder would also NOT report two initial services on the same date due to an IV line requiring a re-start, IV rate not being able to be reached without two lines or accessing a port of a muti-lumen catheter. Typically, only one initial service per DOS/encounter should be reported. However, there are a couple of exceptions to this rule: when protocol or the patient’s condition requires two separate IV access sites or the patient has multiple, separate encounters on the same day, two initial services can be reported. Modifier 59 is required on the second initial code. Documentation should clearly support these exceptions to support the use of modifier 59, which will unbundle these services.
Coding for infusions, injections and hydration can be a challenge, but coders can overcome these by knowing and following the guidelines. Review documentation to ensure complete and accurate coding of these services.
Written by Susan Morton, CPC, CPC-I, CEMC, CGSC, COBGC