Clear Up Your Infusion Confusion with 3 Major Coding Rules

Understand the overlapping coding hierarchies involved

CPT® coding of Injection and Infusion services isn’t easy for newbies and veteran coders alike. You have a myriad of overlapping and intertwining coding rules to follow, which makes proper selection of CPT® codes about as clear as mud.

At the same time, accurate coding of Injection/Infusion services is crucial to minimizing your compliance risks and avoiding payment denials, according to coding guru Gloryanne Bryant in her webinar, “Injection/Infusion CPT® Coding Review.” You must have a solid understanding of the CPT® guidelines and instructions for Injection/Infusion, as well as the medical record documentation requirements.

Here are the three basic coding rules that you must adhere to when billing for Injection/Infusion services:

Rule #1: Pay Attention to the Administration Route

When you’re looking at the treatment note, you can first look for hints to proper coding by identifying the Route of Administration. According to WeInfuse, the Injection/Infusion CPT® codes fall into one of three major categories:

  1. Intravenous Infusions (IV)
  2. Intravenous Pushes (IP)
  3. Injections (Sub-Q, IM)

Don’t forget: The Centers for Medicare & Medicaid Services (CMS) regulations look at the way a drug is administered only as “the physical process by which the drug enters the patient’s body” – not whether a medical professional administers the drug or supervises the administration.

But the administration route hierarchy isn’t the only one you need to understand for Injection/Infusion coding — there is another hierarchy for the type of agent that works in tandem with the administration one.

Rule #2: Understand The Agent Hierarchy

The Injection/Infusion coding hierarchy can be a bit confusing, because it relies on the type of agent being administered and not necessarily which agent was administered first, second, and so on. The hierarchy pyramid for Injection/Infusion coding in a facility setting is as follows:

  1. Chemotherapy/Complex Biologic
  2. Therapeutic/Diagnostic Substance
  3. Hydration

Note: This defined hierarchy is for facilities; in the office/clinic setting, you would base your coding sequence on the primary reason for the encounter, according to the recent Empire State Hematology & Oncology Society Meeting.

Example: A patient is give an infusion or injection push of a non-chemotherapy substance before the chemotherapy is started. Per the hierarchy, chemotherapy would be the initial agent, and the other agent (although given before the chemotherapy began) would be the sequential code, according to Libman Education.

So for your CPT® code choices, you would break down the initial, secondary, and additional Injection/Infusion along with the hierarchy pyramid. For instance, you would code:

  • Initial — Infusion, first hour:
    • 96413 (Chemo/Complex)
    • 96365 (Therapeutic)
    • 96360 (Hydration)
  • Initial — IV Push, first push:
    • 96409 (Chemo/Complex)
    • 96374 (Therapeutic)
  • Secondary — Infusion, sequential:
    • 96417 (Chemo/Complex)
    • 96367 (Therapeutic)
  • Secondary — IV Push, sequential:
    • 96411 (Chemo/Complex)
    • 96375 (Therapeutic)
  • Additional — Infusion, additional hour:
    • 96415 (Chemo/Complex)
    • 96366 (Therapeutic)
    • 96361 (Hydration)
  • Additional — Injection, SQ/IM (per injection):
    • 96401 (Chemo/Complex)
    • 96372 (Therapeutic)

Crucial: When coding Injection/Infusion services, you must follow the “Initial Service” rule, which states that you can have only one initial service code per visit. There are few exceptions to this rule, so be sure that you only ever use one of these codes (96413, 96365, 96360, 96409, and 96374) on any billed visit.

Also, knowing whether the medication ranks as High Level, Low Level, or Hydration is also necessary to properly bill the administration part of the treatment. In most cases, any chemotherapeutic agent will be considered a High Level code, but some medications do fall into a grey area. These medications tend to include biologic/monoclonal antibody products, which Medicare and other insurers may consider High Level medications.

Rule #3: Factor In The Time

What’s more: Yet another challenge in Injection/Infusion coding is documenting the time. The documentation shouldn’t merely state that the infusion ran for 30 minutes — you should have the actual time the infusion started and the time the infusion ended in the record from the nursing staff.

For time-based coding of chemotherapy, therapeutic agent, and hydration administration, you would use the coding categories as follows:

  • 15 minutes or less — IV Push;
  • 16-90 minutes — Initial hour;
  • 91-150 minutes — Initial hour + 1 additional hour;
  • 150-210 minutes — Initial hour + 2 additional hours; and
  • 211-270 minutes — Initial hour + 3 additional hours.

Bottom line: Make sure you have a handle on the different Injection/Infusion classifications and hierarchies, so you can code with confidence. Understanding the basic Injection/Infusion rules for CPT® coding will help you to weather the CMS changes to conditional packaging policies too, Gloryanne Bryant says in her webinar.

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