April 12, 2010

Injections & Infusions: Will the Confusion Ever Go Away?
By Lisa A. Eramo
For The Record
Vol. 22 No. 7 P. 14

Experts recommend addressing gray areas and common mistakes when coding these services.

Codes for injections and infusions comprise only five pages of the more than 700 in the CPT manual, yet they continue to be among the most difficult for coders to decipher. And they’re no walk in the park for nurses charging at the point of care, either.

What service is initial? What constitutes a concurrent infusion? What should be reported when the provider doesn’t document a specific stop time for an infusion? These are just a few of the questions that continue to haunt coders and create a sense of anxiety among providers preparing for recovery audit contractor (RAC) audits.

Automated RAC audits of injections and infusions are already well under way in most states. CGI, the RAC for Region B, is auditing for excessive units reported for IV chemotherapy and nonchemotherapy infusion. CGI is auditing to ensure that providers report only one initial service code unless protocol requires that two separate IV sites must be used. CGI is also auditing for IV hydration to determine whether the service is billed with a maximum number of units (1) per patient per date of service.

Connolly Healthcare, the RAC for Region C, is auditing for code J2505 (Injection, Pegfilgrastim, 6 mg) to ensure that the number of units billed represents the number of multiples of 6 mg administered—not the total number of milligrams. Connolly is also auditing for IV hydration therapy, stating the maximum number of units for CPT code 90760 (excluding claims with modifier -59) should be one per patient per date of service. As of January 1, this code was replaced with 96360.

Likewise, HealthDataInsights, the RAC for Region D, has approved auditing excessive units of IV hydration, as well as code J2505.

Experts say although RACs aren’t yet looking more intensely at injections and infusions, it may only be a matter of time before they do.

Look for Underpayments
Although RACs have primarily identified overpayments thus far, it’s quite possible that many providers are actually underbilling these services, says David Delaney, MD, chief medical officer for MedAptus, a company specializing in intelligent charge capture.

Emergency departments (EDs) are particularly vulnerable, he notes. “Typically, there is significant infusion business that isn’t captured because people think there isn’t enough documentation there to charge for it,” he says. Some EDs may underbill simply out of fear that they could—and probably will—be audited by RACs at some point, he notes.

Experts say RAC audits have certainly created a heightened sense of awareness of the challenges inherent in coding injections and infusions. However, the good news is that the regulatory environment has remained relatively unchanged the last few years.

“In some ways, you’d expect that things would be a little bit easier and more intuitive by now since there have been no major CPT code or definition changes for these codes over the past few years, and yet confusion still reigns supreme out there,” says Jugna Shah, MPH, president and founder of Nimitt Consulting, adding that she receives drug administration-related questions daily.

“The fundamental challenge is that you have very complex care being rendered to very sick patients over a significant period of time often spanning [nursing] shift changes. Then you have a complex hierarchy to which the services must be coded,” says Delaney.

Understand the Hierarchy
The CPT coding hierarchy helps coders and nurses establish the initial service and determine the order in which any remaining services should be reported. Although CPT has further clarified the hierarchy in its 2010 manual to distinguish between physicians and facilities, some coders and nurses still don’t understand that these differences exist, says Joan Benham, CPC, CPC-H, compliance team leader and educator at Baylor College of Medicine who has worked in compliance for the last 10 years, witnessing the evolution—and increasing complexity—of injection and infusion codes.

Consider the following excerpt from the 2010 CPT manual:

• For physicians: The initial code that best describes the key or primary reason for the encounter should always be reported irrespective of the order in which the infusions or injections occur.

• For facilities: The initial code should be selected using a hierarchy whereby chemotherapy services are primary to therapeutic, prophylactic, and diagnostic services which are primary to hydration services. Infusions are primary to pushes, which are primary to injections.

Shah provides this example that demonstrates the complexity of the hierarchy on the facility side: A patient presents to the ED with nausea and receives hydration. Forty-five minutes later, the patient complains of pain and receives an IV push of morphine. In this scenario, it’s incorrect to report hydration as the initial service (96360) with the IV push of morphine as secondary (96375) despite the fact that the hydration was the first service rendered to the patient.

“In so many cases, coders or charging staff must go against what they think is intuitive or logical in order to be consistent with the CPT coding hierarchy,” says Shah.

Address Ongoing Gray Areas
There are many coding and documentation nuances to which coders and nurses must pay attention when reporting injections and infusions according to the CPT hierarchy and guidelines.

One fundamental challenge is that infusions are time-based services, which means documentation must clearly reflect start and stop times. Coders or nurses can’t assume the infusion duration simply based on a physician order, says Shah.

For example, a physician order may indicate a nurse should run 500 cc/hour for one hour starting at noon. Coders or nurses can’t assume that this infusion lasted for exactly one hour simply because that’s how the order stated it should be rendered, says Shah. “It’s likely that the infusion was in fact one hour, but there is always the possibility that it had to be stopped or discontinued for some reason,” she explains.

Neither the Centers for Medicare & Medicaid Services (CMS) or CPT require documentation of an infusion start and stop time; however, it is implied best practice to include both in the record, Shah says, adding that RACs may eventually audit for this documentation and recoup money when it’s absent.

“If you don’t have a stop time, how will you prove that your infusion ran for more than 15 minutes? How will you prove that you are entitled to capturing additional hours of infusion? You just can’t prove that,” she says.

In addition to specific documentation requirements, nearly every injection or infusion code includes one or more parenthetical notes that direct coders down several complicated decision trees. For example, coders or nurses must report 96367 for each additional hour of sequential infusion in addition to a code for the primary procedure. When the additional sequential infusion is provided as a secondary of subsequent service after a different initial service is administered through the same IV access site, they must report 96367 in conjunction with 96365, 96374, 96409, or 96413.

Other similarly confusing notes require coders or nurses to pay attention to which specific substances or drugs are being pushed. For example, code 96376 (each additional sequential intravenous push of the same substance/drug provided in a facility) cannot be reported when the same substance or drug is pushed within a 30-minute time frame.

Some codes are even facility specific, says Benham. For example, code 96376 may be reported only in the facility setting. Likewise, hydration codes 96360 and 96361 are not intended to be reported by the physician in the facility setting per the CPT guidelines. Another example that highlights the differences among settings is code 96372 (therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular). Physicians cannot report this code for injections given without direct physician supervision. Instead, they must report evaluation and management code 99211 (office or other outpatient visit for an established patient). Hospitals, on the other hand, may report 96372 when the physician is not present.

Perhaps most challenging is the fact that coding for injections and infusions simply isn’t intuitive. For example, coders or nurses must report short-duration infusions as IV or intra-arterial pushes. CPT requires providers to report a short-duration infusion (ie, running 15 minutes or less) as an IV or intra-arterial push. This is confusing for coders and nurses charging at the point of care because the medicine bag and infusion line imply that an infusion, not a push, is taking place, says Shah.

Another confusing issue is whether providers must document stop times for IV pushes. Neither CPT nor Medicare has explicitly answered this question, says Shah. CPT defines an IV push as an injection during which the healthcare professional who administers the substance/drug is continuously present to administer the injection and observe the patient or an infusion that is 15 minutes or less.

It’s important to note that this CPT definition references a time element for infusions, not injections, says Shah. When the infusion time is of short duration (ie, 15 minutes or less), coders or nurses must report it as an injection despite the fact that this may seem counterintuitive, she adds.

To complicate matters, questions have been raised about whether a long-duration IV push should be reported as an infusion. Neither the CPT manual nor the CMS have indicated that long-duration IV pushes should be reported as anything other than an infusion, says Shah. “Given an infusion pays more than an injection, hospitals need to be very careful in reporting their services according to the rules described in the CPT book, otherwise they could face compliance implications. Hospitals with questions about this should contact CPT, CMS, or their FI/MAC [fiscal intermediary/Medicare administrative contractor] for further clarification,” she adds.

All of these rules, requirements, and restrictions are enough to make a coder’s or a nurse’s head spin. To make matters worse, CPT Assistant, as well as consultants interpreting that guidance, have disseminated information that is less than clear. In some cases, the information appears to be new or inconsistent with what is stated in the CPT manual, Shah says.

“The bottom line is that it becomes very confusing when CPT Assistant releases a question and answer that seems to contradict the coding hierarchy or other information released in the CPT book,” she says.

Oftentimes, a lack of official guidance is what leads to coding quagmires, says Shah. For example, providers question whether they can report hydration when the patient isn’t dehydrated. Shah says there is no official guidance stating that hydration can only be reported when a dehydration diagnosis code is included on the claim. However, the medical record should include a physician order that clearly outlines the medically necessary reason for the hydration. Documentation that suggests the hydration is performed simply to keep a patient’s line open or to serve as a carrier for other fluids is unacceptable, says Shah.

Another question that commonly arises, and for which there is no official guidance, is whether hydration requires a specific flow rate. “Again, there is no official guidance that dictates a specific flow rate must be present in order for the service to be considered hydration,” says Shah, adding that providers have continued to question the flow rate requirement because auditors have tried to recoup money when a flow rate other than what they expect is present in the record.

“This is troubling because what’s happening doesn’t seem to be correct, and if hospitals cannot get any relief by contacting the auditing agency—their FI/MAC, the OIG [Office of Inspector General], RAC, etc—then they should raise the issue with the American Hospital Association and CMS,” she says.

The lack of official guidance, though frustrating in some cases, can also be advantageous, says Shah. “We need to be careful what we ask for in terms of more and more guidance because we don’t want to find ourselves with guidance that may not make sense or that may be onerous to implement,” she says. “Let’s leave the practice of medicine to the clinicians and not ask Medicare or the FIs to more prescriptively tell us what to do. When auditors begin to behave in ways that go against official guidance, that’s when hospitals should raise questions.”

The best thing providers can do is challenge consultants and others who provide answers without any official guidance to back them up, says Shah. “As a consultant and educator on this topic, my advice to people is that if you hear something that doesn’t seem right, you have not heard before, or if you have heard the opposite information from someone else, challenge it regardless of who is telling you this information,” she says. “Force them to back up their claims by giving you the reference or the source of the official written guidance.”

— Lisa A. Eramo is a freelance writer and editor in Cranston, R.I., who specializes in HIM, medical coding, and healthcare regulatory topics.

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