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Think Outside the Box for Injection and Infusion Coding Solutions
By Lisa A. Eramo

Injections and infusions are perhaps two of the most challenging services to code due to complex guidelines and code descriptions. The bottom line is that documentation should always reflect the services rendered, says Joan Benham, CPC, CPC-H, compliance team leader and educator for Baylor College of Medicine. For injections and infusions, this includes the following:

• diagnosis;

• name of the drug or substance provided;

• route of administration (eg, infusion, push, injection);

• length of time for infusions, including a start and stop time;

• site of administration (eg, arm, chest); and

• method of administration (eg, initial, sequential, piggyback/concurrent).

The documentation of piggyback/concurrent drugs can be confusing because providers may not document the specific site through which the drug is infused, says Benham. If the drugs are truly concurrent (ie, going in at the same time and through the same line/port), coders can report add-on code 96368 (concurrent infusion) in addition to a code for the primary procedure (eg, 96365, 96366, 96413, 96415, 96416). If the drugs are not concurrent, code 96368 cannot be reported.

Another challenge for coders is distinguishing the plethora of different drugs that can be pushed or infused, she adds. CPT divides codes into these three categories, depending on how the drug or substance is used: hydration services; therapeutic, prophylactic, and diagnostic services; and chemotherapy services.

Benham says it’s important for coders to understand which drugs are used for each of the above purposes because this information determines code selection. For example, if saline is used for hydration, coders would report 96360 or 96361. However, drugs used for therapy, prophylaxis, or diagnosis are located in the 96365 to 96379 category.

If nurses—rather than coders—are charging for injections and infusions at the point of care, providers may want to consider a software solution. MedAptus offers the Infusion Services, a component of Facility Intelligent Charge Capture, which manages and streamlines the complex requirements of coding injections and infusions. The technology allows nurses to input the medications they injected and/or infused as well as the duration, and the information is translated behind the scenes into compliant codes that are charged according to the CPT hierarchy. For example, the technology automatically identifies the initial service, charges for additional units of infusion (when applicable), and forces nurses to enter a stop time.

“This is a tremendous fit for utilizing technology to mask the complexity of the coding,” says David Delaney, MD, chief medical officer for MedAptus. “ It also leads to RAC [recovery audit contractor] survivability.”

However, even if providers can’t afford to implement a software solution, consider creating a template that encourages nurses to at least document the name of the drug, start/stop time, and route of administration, says Benham. “If someone else is auditing, such as a RAC, the clearer you can make it for them, the better off you are,” she adds.

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