Coding Infusions and

Medications

Professional vs. Facility

Lisa Hornick BA, CPC, CPMA, CEDC, CPhT

1. Learn about the medications you are coding

2. Type of medication and route of administration

3. How is medication the supplied?

4. Do you have the NDC in your record?

5. www.dailymed.gov

General Medication Coding

Vial Image Examples

1. Does your carrier require you to use the smallest vial?

a) Medicare Claims Processing Manual Chapter 17 – Drugs and Biologicals

2. Is the NDC indicated? – This information will enable the most accurate coding

3. When is it appropriate to modifier JW?

Policy: Effective January 1, 2017, providers and suppliers are required to report the JW modifier on Part B drug claims for discarded drugs and biologicals. Also, providers and suppliers must document the amount of discarded drugs or biologicals in Medicare beneficiaries’ medical records.

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/JW-Modifier-FAQs.pdf

Coding for Waste

Coding HCPCS

Locate the most appropriate code

Make sure your unit of measurement

is correct; i.e., mg, gm, mcg, cc, ml –

if not convert to match

Code the appropriate number of units

Conversions

1. What type of infusion is taking place during this encounter?

a. Hydration

b. Chemotherapy/Biologic

c. Antibiotic/Other infusions

2. How long is the infusion must have start/stop times?

3. Must be longer than 15 minutes to fall into the infusion coding

4. Less than 15 minutes injections code sets

Infusion Coding

• ***Code only 1 initial per encounter***

• 96365-96368 – therapeutic IV infusions

• 96369-96371 – therapeutic subcutaneous infusions

• 96413-96417 – chemotherapy infusion codes **these codes are used for biologics also**

• 96360-96361 – hydration codes (NS D5W)

• ***Do not code hydration codes when used to keep line open while infusing other medications***

Infusion Code Sets

• The CPT guidelines and hierarchy must be followed:

• One code in each category of intravenous infusion and injection drug administration codes designated as the “initial” service.

• Order of service delivery does NOT determine what is “initial”.

• Typically only one “initial service” will be reported per encounter - unless there is more than one IV access site.

• Chemo 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.

• The hierarchy does not apply to SQ/IM injections, only intravenous injections.

Guidelines

Hierarchy• When coding for Facility, the “Initial” code should be selected using the

hierarchy below:

• Chemotherapy Infusions

• Chemotherapy IV Push

• Chemotherapy Injections

• Non-chemotherapy Therapeutic, Prophylactic or Diagnostic Infusions

• Non-chemotherapy Therapeutic, Prophylactic or Diagnostic IV Push

• Non-chemotherapy Therapeutic, Prophylactic or Diagnostic Injections

• Hydration Infusions

• When coding injections and infusions, always follow the hierarchy regardless of the order in which services were provided. Chemotherapy services are always primary, meaning you must report them first.

Record Requirements

• Must be ordered by a physician or qualified provider

• Documentation must support medical necessity

• EACH substance administered is:

• Clearly documented, no abbreviations (some abbreviations are acceptable just be sure not to use the ones that are deemed unacceptable)

• Route and Site are easily discernible

• Start and stop times for EACH substance are documented

• Amount of EACH substance given is documented

Sequential vs. Concurrent

• Sequential is one after the other through the same

venous access site.

• Concurrent is at the same time, through the same

access site –

• May Occur through a different lumen of the

catheter

Example – Cisplatin and Leucovorin

• Multiple drugs added to one bag of fluids are NOT a

concurrent infusion.

• Only one “initial” service code should be reported, unless two separate IV sites are required;

• Hydration codes are reported from the 31st minute of infusion

• Do not charge hydration when provided for 30 minutes or less;

• Concurrent infusion is only reported once per encounter;

• Sequential is one after the other; concurrent is at the same time. In order to report a concurrent administration, the drugs cannot simply be mixed in one bag; there must be more than one bag;

• Infusions of 15 minutes or less are reported with an IV push code;

• Injections are coded per injection, not per medication;

• Each additional sequential IV push of the same substance must be greater than 30 minutes;

• Vaccination codes utilize an administration code 90460-90474 in addition to the vaccine/toxoid 90461-90479;

Coding Tips

Hydration Therapy• Hydration must be medically reasonable and necessary. If

documentation supports a clinical condition that warrants hydration, other than one brought about by the requirements of a procedure, the hydration may be separately billable.

• When fluids are used solely to administer the drugs, i.e. the fluid is merely the vehicle for the drug administration, the administration of the fluid is considered incidental hydration and not separately billable.

• CPT instructions require the administration of a hydration infusion of more than 30 minutes in order to allow the coding of hydration as an initial service. Hydration of less than 30 minutes is not separately billable. The charges for an administration of 30 minutes or less should be reported with an appropriate revenue code but without a HCPCS or CPT code. Hydration therapy of 30 minutes or more should be coded as initial, 31 minutes to one hour and each additional hour should be listed separately in addition to the code for the primary infusion/injection.

• Do not charge for hydration and infusion during the same time interval;

• Hydration consists of pre-packaged fluid and electrolytes (e.g., normal saline, D5 1⁄2 normal saline + 30 mEq KCl/liter);

• Do not charge for services integral to a procedure (e.g., drugs given during CPR or prior to intubation);

• Infusion is for the administration of substances/drugs. When fluids are used to administer the drug(s), the administration of the fluid is considered incidental hydration and is not separately reportable;

• Hydration is not coded on a concurrent service.

Coding tips continued

Insufficient Documentation Example

• In this example there is sufficient

documentation of the order

• No documentation that this was

completed at this visit

• No medication administration record

(MAR)

Sufficient Documentation Example

• All necessary information is

documented

• Medication clearly indicated

• Dosage clearly documented

• Number of vials with lot and

expiration clearly documented

• Patient/Provider/Staff/DOS

documented

Ambulatory Surgery Centers (ASC)• The Medicare Carriers Manual, section 10.1, defines an ASC as a distinct entity, operating exclusively to furnish outpatient

surgical services. ASCs are not in the business of providing office visits, laboratory services, diagnostic tests, etc

• A hospital-operated facility may be considered by Medicare to be either an ASC or a provider-based department of the hospital, as defined in 42 CFR 413.65. To provide and bill services performed in an ASC, the ASC must enter into a participating provider agreement with the Centers for Medicare & Medicaid Services (CMS).

• An ASC must be certified and approved to enter into a written agreement with CMS. Participation as an ASC is limited to any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization and in which the expected duration of services would not exceed 24 hours following an admission. An unanticipated medical circumstance may arise that would require an ASC patient to stay in the ASC longer than 24 hours, but such situations should be rare.

• The regulatory definition of an ASC does not allow the ASC and another entity, such as an adjacent physician's office, to mixfunctions and operations in a common space during concurrent or overlapping hours of operations. CMS does permit two different Medicare-participating ASCs to use the same physical space, so long as they are temporally separated. That is, the two facilities must have entirely separate operations, records, etc., and may not be open at the same time.

• It’s important to use the proper form when submitting claims. Medicare pays for ASC services under Part B and requires the CMS-1500 claim form. Some third-party carriers will accept the CMS-1500 form, while others allow the UB04.

Hospital Outpatient Prospective Payment System (OPPS)

• Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Organ Procurement Organization Reporting and Communication; Transplant Outcome Measures and Documentation Requirements; Electronic Health Record (EHR) Incentive Programs; Payment to NonexceptedOff-Campus Provider-Based Department of a Hospital; Hospital Value-Based Purchasing (VBP) Program; Establishment of Payment Rates under the Medicare Physician Fee Schedule for Nonexcepted Items and Services Furnished by an Off-Campus Provider-Based Department of a Hospital

• This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2017 to implement applicable statutory requirements and changes arising from our continuing experience with these systems. In this final rule with comment period, we describe the changes to the amounts and factors used to determine the payment rates for Medicare services paid under the OPPS and those paid under the ASC payment system. In addition, this final rule with comment period updates and refines the requirements for the Hospital Outpatient Quality Reporting (OQR) Program and the ASC Quality Reporting (ASCQR) Program.

Hospital Outpatient Prospective Payment System (OPPS)

• Medicare Claims Processing Manual Chapter 4

• 10.1.1 - Payment Status Indicators

• (Rev. 1445; Issued: 02-08-08; Effective: 01-01-08; Implementation: 03-10-08)

• An OPPS payment status indicator is assigned to every HCPCS code. The status indicator identifies whether the service described by the HCPCS code is paid under the OPPS and if so, whether payment is made separately or packaged. The status indicator may also provide additional information about how the code is paid under the OPPS or under another payment system or fee schedule. For example, services with status indicator A are paid under a fee schedule or payment system other than the OPPS. Services with status indicator N are paid under the OPPS, but their payment is packaged into payment for a separately paid service. Services with status indicator T are paid separately under OPPS but a multiple procedure payment reduction applies when two or more services with a status indicator of T are billed on the same date of service.

• The full list of status indicators and their definitions is published in Addendum D1 of the OPPS/ASC proposed and final rules each year. The status indicator for each HCPCS code is shown in OPPS Addendum B.

ASC Payment Indicators

• Payment indicators determine

whether separate reimbursement is

issued in an ASC

• HCPCS manual does list the status

off to the right

• Green - ASC Payment Indicator

Lidocaine

• Medicare will reimburse for

injectable drugs e.g., drugs that

cannot be self-administered. Bear in

mind however, that Medicare does

not reimburse for anesthetics even

if used in an injection, as they

consider the drug to be a topical or

local that is bundled into the

procedure.

OPPS Status Indicators

• OPPS Status Indicators determine

whether separate reimbursement is

issued in to the OPPS

• HCPCS manual does list the status

off to the right

• Purple - ASC Payment Indicator

Example • Patient is coming in for infusions. Patient is receiving Herceptin (trastuzumab) 2 mg/kg on his 4th treatment, patient weighs 100

kg – dose to be administered is 200 mg over 30 minutes. Patient is pre-medicated with 50 mg diphenydramine (Benadryl) 50 mg IV Push.

• Patient/Provider/Start/Stop time/DOS/Lot/Exp – all documented sufficiently

• Codes to report for this encounter for a professional place of service 11 (office):

• J9355 x 20 units (J9355 – trastuzumab, 10 mg) **remember this is a multi-use vial only report the units used not the vial or waste**

• J1200 x 1 unit (J1200 – diphenhydramine HCl, up to 50 mg)

• 96413 x 1 unit (96413 - Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug)

• 96366 x 1 unit (96316 - Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure)

Example Continued• Status Indicators highlighted

• 96366 – IT - Traditionally packaged item. Payment is bundled into the ASC payment for the procedure.

• 96413 – IN - Nonsurgical procedure not Medicare allowable in an ASC

• J1200 – N1 - Packaged procedure/item; no separate payment made

• J9355 – K2 - Drugs and biologicals paid separately when provided integral to a surgical procedure on ASC list; payment based on OPPS rate

Lidocaine• J2001 – Injection, lidocaine HCl for

intravenous infusion, 10 mg

• Lidocaine hydrochloride

administered intravenously is

specifically indicated in the acute

management of (1) ventricular

arrhythmias occurring during cardiac

manipulations, such as cardiac

surgery and (2) life-threatening

arrhythmias which are ventricular in

origin, such as occur during acute

myocardial infarction.

FAQ’s• Can supplies such as syringes or tubing be billed with an infusion encounter? No, supplies used during

an infusion cannot be billed in addition to the infusion code as they are considered a component of the service

• Can an infusion service be billed with a nurse visit (99211)? No, a nurse visit (99211) cannot be billed with any of the drug administration codes. Currently CPT indicates that infusion services typically require direct supervision with these services and nurse’s work is an integral part of the main infusion procedural codes 96401-96413

• What is the difference between IV push and infusion? An intravenous push (intravenous injection) is an infusion of 15 minutes or less. In or der to bill an intravenous infusion, delivery must require more than 15 minutes for safe and effective administration

• Does the infusion time start once venous access is obtained? No, you do not start timing the infusion until you begin to administer the fluids. If you obtain venous access prior to a procedure and start a slow drip of normal saline to keep the line open (TKO) for later you would not charge for administration of the TKO

Medicare Status Indicator

• What is a status indicator?

• The status indicator is currently the

1st position of the Revenue Center

Payment Method Indicator Code.

The payment method indicator

code is being split into two 2-byte

fields (payment indicator and

status indicator).

Referenceshttp://bok.ahima.org/doc?oid=105755#.WKnC2k3rvcs

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/JW-Modifier-FAQs.pdf

https://dailymed.nlm.nih.gov/dailymed/index.cfm

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/ASCs.html

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-

Items/CMS-1656-FC.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending

http://www.accessdata.fda.gov/drugsatfda_docs/label/2014/018388s084lbl.pdf

http://www.medline.com/product/Lidocaine-Hydrochloride-and-5-Dextrose-by-Baxter-Healthcare/Z05-PF61944

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html?redirect=/nationalcorrectcodinited/

http://www.mowles.com/CodingForTheOfficeAndSupplies.pdf

https://www.ahcmedia.com/articles/1552-sharpen-your-pencils-abbreviations-are-disappearing

http://www.waybuilder.net/free-ed/Resources/PubServ/EMS/EMS%20Primer/emsPrimer01.asp?iNum=604

http://www.rheumatology.org/Practice-Quality/Administrative-Support/Coding/Coding-Support/Infusion-FAQs

https://engage.ahima.org/HigherLogic/System/DownloadDocumentFile.ashx?DocumentFileKey=092b0c68-b706-46b4-a04e-2bcf69cdd730

https://www.cms.gov/apps/ama/license.asp?file=/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/Downloads/2017-January-ASC-

Addenda.zip

Optum 360 2017 HCPCS Level II Expert

Medication & Infusion Coding

Lisa Hornick BA, CPC, CPMA, CPhT

lisahornick@yahoo.com

Questions