By Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P
Injection and infusion coding is a challenging area, thanks to vast instructional notes, hierarchy rules, and payer-specific policies.
Current Procedural Terminology (CPT) defines the terms “injection” and “infusion” as:
- Injection—delivers a dosage in one “shot,” rather than over a period of time; may be administered by various routes, including subcutaneous, intramuscular, intraarterial, and intravenous
- Infusion—administration of intravenous fluids and/or drugs over a period of time for diagnostic or therapeutic purposes
Medication that is given for an immediate effect (typically within 3-5 minutes) is an injection. Medication or solution that is provided through saline or other solutions given over a period of time (usually 30 minutes or more) is an infusion.
Injection and Infusion Coding Scenarios
Case: A 66-year-old patient arrives in the ER and receives a two-hour therapeutic infusion of a drug. One hour later, he receives an IV push of the same drug. How is this reported?
Answer: Coders should use 96365 for the first hour of infusion, 96366 for the second hour of infusion, and for the IV push of the same drug.
Case: A 62-year-old patient comes to the ER complaining of pain in his legs and back, saying he feels nauseous and lightheaded. The hospital starts an IV and gives a bolus of normal saline to hydrate the patient from 7-7:20 a.m. At 7:15 a.m. an IV push of morphine is given. How is this reported?
Answer: Code 96374 is reported for the IV push of morphine. No code is assigned for the hydration since the time is less than 30 minutes.
Injection and Infusion Coding
Injection and infusion codes, including hydration and chemotherapy administration, are found in the CPT codebook beginning with code 96360 and ending with code 96549. There are extensive instructional notes within this subsection to assist coders. Coders should be familiar with these notes and consult them each time a code is assigned from this subsection.
This section of notes includes a list of items included in an injection or infusion service, definitions of the various types of infusions, proper coding of multiple infusions, hierarchy rules, and units of time instructions.
The services included (not reported separately) are:
- Use of local anesthesia
- Intravenous (IV) start
- Access to indwelling IV, subcutaneous catheter, or port
- Flush at conclusion of infusion
- Standard tubing, syringes, and supplies
Multiple infusions of different substances or drugs can be reported separately. In situations where multiple drugs are administered on the same date of service, the coder should assign only one initial service code if the medications are given at the same IV site. When a subsequent or concurrent injection or infusion is done, a subsequent or concurrent code is reported. For example, if a patient receives an IV push following an initial one-hour infusion, the IV push is reported as a subsequent service.
Reporting of multiple infusions of the same substance/drug is slightly different. The initial code is reported for the first infusion. Any subsequent infusions are reported based on the individual times of the infusions using the appropriate add-on code.
The notes within this subsection define initial infusion, sequential infusion, and concurrent infusion. The initial infusion for physician reporting is the primary reason for the encounter. For facility reporting, however, the initial infusion is determined by using the hierarchy as depicted in Figure 1. A sequential infusion is defined as an infusion or IV push of a new substance/drug following a primary or initial service. A concurrent infusion is one in which a new substance/drug is infused at the same time as another substance/drug.
An intravenous (IV) push is defined by CPT as: “(a) an injection in which the healthcare professional who administers the substance/drug is continuously present to administer the injection and observe the patient, or (b) an infusion of 15 minutes or less.” There are multiple codes for IV push and the code selection is based on whether the push is initial or not and the time that elapses between pushes for multiple pushes of the same non-chemotherapeutic substance or drug.
When coding hydration services, there are important factors to consider. A hydration service cannot be reported when fluids are used solely to administer drug(s), or to keep the line open. In addition, do not report hydration if it is performed concurrent to another infusion. Hydration provided before or after chemotherapy is appropriate to charge, but not hydration running during chemotherapy. Hydration should be reported with other drug administration services, but typically not as “initial.” Medically necessary hydration is reported with the add-on hydration code when another service is reported as initial. And lastly, hydration services of 30 minutes or less cannot be reported.
Therapeutic infusions (chemotherapy and non-chemotherapy) have their own set of coding rules. The initial hour of infusion is 16 to 90 minutes. Add-on codes are reported for additional hours of infusion beyond the first only after more than 30 minutes have passed from the end of the previously billed hour (i.e., 91 minutes for an additional hour). Time documentation is critical since separate codes exist for initial, sequential, and concurrent infusions. It is important to note that infusions of 15 minutes or less are reported using an IV push code.
Figure 1 – Injection and Infusion Hierarchy for Facility Reporting
Figure 1 depicts the hierarchy rules associated with facility reporting of the initial injection or infusion service. If a patient receives two or more of these services, the service that is higher on the pyramid is reported as the initial service. For example, if the patient is receiving a chemotherapy injection and a hydration infusion, the chemotherapy injection is reported as the initial service, followed by the hydration infusion. The hierarchy takes precedence over parenthetical instructions for add-on codes. Keep in mind that this hierarchy applies to facility reporting, not to physician reporting.
Figure 2 – Injection and Infusion Decision Tree
Below is a list of questions to consider when assigning injection and infusion codes.
Addressing Coding Compliance Concerns
In an environment of increasing external audits by governmental agencies and third-party payers, hospitals must monitor and resolve drug administration coding, billing, and charge capture issues. Some of the current Centers for Medicare and Medicaid Services’ recovery audit contractor initiatives focus on units of service reporting in injection and infusion coding. Contractors are looking for excessive units of chemotherapy and non-chemotherapy medications, correct reporting of IV hydration (i.e., use of modifier -59), and use of multiple initial service codes.
Those assigning injection and infusion codes must have a thorough knowledge of the National Correct Coding Initiative edits, which provide edits on Medicare claims to check for irregularities. Close adherence may help avoid negative audit results.
Another topic to consider is who is “assigning” the drug administration codes. Questions can arise about whether these services should be charge-driven at the point of care, coded by the HIM department, or a combination. There is not one specific solution to these charge capture questions. It depends on factors such as staff capacity, organization culture, volume and mix of services, types of tools available, EHR or other electronic documentation, knowledge and expertise of staff, and budget issues.
To help mitigate compliance concerns, follow these tips:
- Adhere to American Medical Association CPT information, including parenthetical notes and text
- Make documentation the first priority
- Collaborate with nursing, clinical, and HIM staff to verify, validate, and code based on documentation
- Work with staff to resolve edits and provide feedback
- Develop written policies and procedures
- Conduct internal and external audits periodically
- Provide education to charging and coding staff
- Seek guidance when information is confusing/inconsistent
- Implement processes to secure revenue integrity
AHIMA. CPT Coding for Injections and Infusions. Audio Seminar, May 8, 2012.
American Medical Association. CPT Assistant. Chicago: AMA, 2001.
American Medical Association. CPT Professional Edition. Chicago: AMA, 2012.
Melanie Endicott (firstname.lastname@example.org) is a director of HIM Solutions at AHIMA.
"Taking the Sting out of Injection and Infusion Coding"
Journal of AHIMA