Infusion Confusion What’s Your Solution!! 2008 JOKERS ... · Infusion Confusion What’s Your Solution!! ... What’s Your Solution!! 2008 JOKERS’ WILD EDITION Presented by: Andrea

Infusion ConfusionWhat’s Your Solution!!

2008 JOKERS’ WILD EDITION

Infusion ConfusionInfusion ConfusionWhatWhat’’s Your Solution!!s Your Solution!!

2008 JOKERS2008 JOKERS’’ WILD EDITIONWILD EDITION

Presented by:Andrea Clark, RHIA, CCS, CPH - PresidentHealth Revenue Assurance Associates, [email protected]

Slide #22008 Health Revenue Assurance Associates, Inc. All Rights Reserved.Unauthorized distribution, regardless of media, strictly prohibited by law.

DisclaimerDisclaimer The information disseminated in this seminar, whether oral or contained in

written materials, is provided for general guidance and is intended to offer theuser general information. The information provided is not intended to replace orserve as substitute for any compliance advice, consultation or service. Youshould consult with a professional in the respective area of concern.

Therefore, the information is provided "as is" without warranties of any kind, express or implied, including accuracy, timeliness and completeness.

In no event shall Health Revenue Assurance Associates, Inc. nor its relatedshareholders, managing directors, principals, agents or employees be liable forany direct, indirect, incidental, special, exemplary, punitive, consequential orother damages whatsoever without regard to the form of any action, includingbut not limited to contract, negligence or other tortuous actions, arising out ofor in connection with this Seminar.

CPT is a registered trademark of the American Medical Association. All othertrademarks and copyrights are hereby acknowledged.


Objectives ForObjectives ForTodayToday

Become skilled at 2008 drug administration guidelinesfrom the CPT manualFacility Drug Hierarchy and NEW CPT codes

Step-by-step scenarios to include ED, IV Therapy, andChemotherapy

Recognize charge capture opportunities and risks via CDM Understand current CCI edits and modifier 59 Discuss the most frequently asked questions (FAQ) Identify insufficient documentation along with process

improvement Explore operational issues facing each facility along with

“best practices” Design internal audit techniques for your facility


References Utilized forReferences Utilized forSession Today ComplianceSession Today ComplianceSecurity for Your FacilitySecurity for Your Facility

2008 CPT Manual along with instructions – Transmittal 1417 Per CMS – “For CY 2008, hospitals are reminded to use the full set of

CPT codes for billing drug administration services provided in thehospital outpatient department setting. In addition, hospitals are to reportall drug administration services, regardless of whether they areseparately paid or are packaged.”

CPT Assistants 2007 – Drug Administration Series May, June andSeptember and November/December Q/A

Current CCI Manual Instructions Federal Register Final Rules 2008 published November 2007 CMS Frequently Asked Questions (FAQ) Fiscal Intermediaries Questions/Answers

National Government Services, Noridian, BCBS Kansas, RiverBend If conflicting with CPT guidelines be sure to point it out to the FI

CPT Knowledge Base – American Medical Association (AMA) American Society of Clinical Oncology (ASCO)

HCPCS Coding Clinic – American Hospital Association (AHA)


CAUTION: BeCAUTION: BePrepared to ReactPrepared to React

Work as a Revenue Cycle TEAMDiscourage SILO management of this

process Can contribute to failure and revenue loss along

with compliance risksKeep an OPEN mind for NEW Operational

process (i.e. charge/code application) tosecure APC Revenue Integrity

HIM Revenue Cycle Specialists


Principal ofPrincipal of INITIALINITIALDrug AdministrationDrug Administration

2008 Instructions for Facilities When these codes are reported by the

FACILITY – the following instructions apply – The initial code should be selected using a

hierarchy wherebychemotherapy services areprimary to therapeutic, prophylactic anddiagnostic service which are primary tohydration services

Infusions are primary to pushes which areprimary to injections

This hierarchy does not apply to physicians



Chemotherapy infusionsChemotherapy injections (IVP, IM)Non-chemotherapy, therapeutic infusions

(IVPB)Non-chemotherapy, therapeutic injections -

IV pushes (IVP)Hydration infusion

Injection (IM, SQ) do not fall into thehierarchy and can be reported as manytimes as ordered and resulted


Principal ofPrincipal of INITIALINITIALDrug AdministrationDrug AdministrationHierarchyHierarchy

Important to note - “hierarchy” has beenestablished throughout the CPT manual withinstructions and parenthetical phrases

Keys to the hierarchyClue 1 – review note under 90775 which states 90760

cannot be reported 90775Clue 2 – review note under 90766 which states 90760

cannot be reported with 90766Clue 3 – review note under 90768 which cannot be

reported with 90760/90761Clue 4 – final note under 90761 which cannot be

reported with 90775



One code in each category of drug administrationcodes has been designated as the “initial” service.

Your hand “dealt” must have only ONE initial

When administering multiple infusions, injections orcombinations, only one "initial" service code shouldbe reported, unless medical resonable andnecessary requires that two separate IV sitesmust be used. (CCI Manual)

Per Administar (NGS) – if two lines accessed forconvenience (i.e. decrease time of infusion) they are notbillable as separate lines


ChemotherapyChemotherapyExampleExample

90767 x 1 = Decadron (35 minutes)

90775 x 1 = Aloxi (IV Push) J2469 x 1

96413 x 1 = Eloxaton (Chemotherapy 2 hr 20 min)

96415 x 1, J9263 x 374

90768 x 1 = Leucovorin concurrently infused with Eloxaton

96411 x 1 = Flurouracil (Chemotherapy IV push 10 min)

90775 x 1 = Benadryl (IV Push)

96417 x 1 = Avastin (Bevcixumab), J9035 x 116


IV Therapy ExampleIV Therapy ExampleSequentialSequential

90765 x 1 Vancomycin – 90 minutes (cannot code/charge for 90766 due tonot greater than 30 min)

90767 x 1 Ertapenem – 30 minutes or sequential infusion

Both drug products are Packaged or SI N – will be charged appropriatewith or without HCPCS.


RemicaidRemicaid ExampleExample

96413 x 1 = 80 minutes, 90775 x 3, J1745 x 25 (250 mg)


IV PushesIV Pushes

Same/Different DrugSame/Different Drug

Rocephin = 90765 x 1

12:30 Demoral IVP = 90775 x 1

Phenergan IVP = 90775 x 1

Td = 90471 x 1

13:50 Demoral IVP = preparedindividually and timerequirement met = 90776; ifprepared one time andadministered in portions = noCPT assignment

15:20 Morphine IVP 90775 x 1

16:45 Morphine IVP =prepared individually and timerequirement met = 90776; ifprepared one time andadministered in portions = noCPT assignment


Hydration ExampleHydration Example

90765 x 1 Zosyn, 90761 x 1 – Zosyn stopped @22:20however NS 500cc ran until 23:20 which would qualifyfor greater than 30 min.


ED SequentialED SequentialExampleExample

90765 x 1, 90767 x 1


Hydration ExampleHydration Example

90761 x 2 (11:34 to13:35)

90774 x 1 IVP Zofran


CDM Issues forCDM Issues forInjections and InfusionsInjections and Infusions

Revenue Code Examples - 45X, 26X, 76X, 33X, 92X

UB-04 Claim Form 90760–90768 0260 or report the revenue code that

reflects where the procedure was performed 90772–90773 report the revenue code that reflects

where the procedure was performed 90774–90776 report the revenue code that reflects

where the procedure was performed


CDM Issues forCDM Issues forInjections and InfusionsInjections and Infusions

Line Item Descriptions 2008 Changes

90760 - Intravenous infusion, hydration; initial, 31minutes to 1 hour

90761 - Intravenous infusion, hydration; eachadditional hour (list separately in addition to primaryprocedure) (greater than 30 minutes)

Do not report intravenous infusion for hydration of 30minutes or less

Data Transference Issues Review Detail Bill for “Roll-up” Units of Service


CCI VersionCCI VersionDrug AdministrationDrug Administration

Column 1Code Description Modifier12002 Repair superficial wound(s)

90765 Ther/proph/diag iv inf, init 190772 Ther/proph/diag inj, sc/im 1

90775 Ther/proph/diag inj add-on 1

90761 Hydrate ivinfusion, add-on

90765 Ther/proph/diag ivinf, init90772 Ther/proph/diag inj, sc/im 1

90772 Ther/proph/diag inj, sc/im

90775 Ther/proph/diag inj add-on

Example1 ED


CCI VersionCCI VersionDrug AdministrationDrug Administration

Column 1Code Description Modifier90761 Hydrate ivinfusion, add-on90772 Ther/proph/diag inj, sc/im90775 Ther/proph/diag inj add-on96413 Chemo, ivinfusion, 1 hr

90772 Ther/proph/diag inj, sc/im 1

96415 Chemo, ivinfusion, addl hr

96417 Chemo ivinfus eachaddl seq

Example2 Chemotherapy


CCI VersionCCI VersionDrug AdministrationDrug Administration““Double WhammyDouble Whammy””

Column 1Code Description Modifier90772 Ther/proph/diag inj, sc/im

96523 Irrig drug delivery device 096523 Irrig drug delivery device

Example 3Ambulatory Care

First Level Trigger (Payment Policy) - 96523 is statusindicator Q which means if there is a S-X-V-T SI on theclaim with a SI Q – Q will be packaged.

Second Level Trigger (CCI Edit) – this states that CMSwill not allow 96523 on the same date of service with 90772or IM injection.

Payment Policies Q and CCI Edits are two different levelsof “triggers”.


Commonly AskedCommonly AskedQuestionsQuestions

Time DocumentationIM/SQ Injection(s)IV Push(es)IVPBHydrationChemotherapyCPR and injectionsPost Operative injections/infusion


Time DocumentationTime DocumentationRequirements for DrugRequirements for DrugAdministration ServicesAdministration Services

Question: What does CMS consider as valid and completedocumentation to support the charging of drug administrationservices?

Answer: Let’s Begin with Transmittal 785 Infusion Time – Hospitals are to report HCPCS codes that

describe the actual time over which the infusion isadministered to the beneficiary for time-specific drugadministration codes. Hospitals should not include in theirreporting the time that may elapse between establishmentof vascular access and initiation of the infusion.



Per AMA – “Infusion time is measured when the infusate isactually running: per and post time are not counted. It isrecommended to document infusion start and stop times.”

CMS – Has not provided national guidance o how hospitalsshould bill when infusion start/stop times aren’t recorded

CMS – Indicates that it has the expectation that hospitals willdocument time otherwise CMS has a difficult timeunderstanding how services would be billed appropriately

Drug administration codes are “time-based” codes, therefore a“time-frame” should be clearly documented



From AdminaStar Dec 2006 FAQ #9: “The documentation must support what was billed. Time up and

time down, start and stop times, “given over…” are all appropriatemeans of documenting administration times. The important thingto remember is that a reviewer must be able to determine theactual amount of time a medication infused from the records, notjust the “ordered” infusion time.”

From Wheatland (BCBS Kansas) – Hospitals are to report codes according to CPT instructions. CPT

instructions are to use the actual time over which the infusions isadministered to the beneficiary for time specific drugadministration codes.

“It is this intermediary’s interpretation that the actual infusion startand stop times should be documented.”



Riverbend’s Take on the Issue – “Ideally the start and stop time of all infusions should be

documented in the patients medical record. Best practice is forall staff to provide thorough documentation of the infusionservice which will include a description of the procedure as wellas a start and stop time.”

“When documentation lacks a stop time, the type ofadministration service is not at the discretion of the facility andthe following instructions should be followed.”

Medication records will often include the volume and cc/hourand when collaborated in the nursing notes may be used tocalculate the stop time. Example One: The physician orderstates 100cc of drug/substance were administered at 60cc perhour. One can calculate that it would take 1 hour and 20minutes for the total administration of the drug/substance. Inthis situation the facility may report one hour of IV infusion.


RiverBendRiverBend’’s Take ons Take onDocumentation ofDocumentation ofInfusionsInfusions

Example Two: When the physician order or nursingdocumentation is insufficient to calculate the totaladministration time of a drug/substance and thebagged medication includes instructions on theappropriate administration of the drug/substance,these packaged instructions may not be used tocalculate the administration time.

Careful review of physician orders anddocumentation will be necessary to determine theappropriate services that may be reported when IVinfusion stop times are not noted in the patientmedical record.



Keep in mind other services regarding time requirements

CMS requires documentation of all therapy minutes. This is not thetime the therapist spends with the patient, but a record of the timethe patient spends receiving therapy. The actual minutes oftreatment must be documented in the patient's records andsubmitted to AdminaStar upon request for review. The treatmenttime can be documented per modality or documented in the recordas time in and time out (excluding rest breaks). Thisdocumentation supports the number of units billed in relation tominutes of therapy received. Failure to provide documentation ofminutes to support billed units could result in claim denial.

Is there a difference between this and time requirements foryour infusions, injections and chemotherapy???


Time DocumentationTime DocumentationRequirements for DrugRequirements for DrugAdministration ServicesAdministration Services Question: If a stop time is not recorded for an infusion

administration, can an IV push injection be reported? What ifIVPB provided and lack of stop time – can we report unit of 1 or90765?

Answer:Answer: What does your FI and/or Compliance Officer say? CMS has stated that a short-duration infusion (i.e., less than 15 minutes)

can be reported as an IV push injection but does not state anything aboutwhat can/cannot or should/should not be reported if an explicit “stop” time ismissing…

From an auditing standpoint can you justify reporting an IV push forsomething that is not a push simply because a stop time was not recorded?

Are we taking this directive too literally due to incomplete, insufficientdocumentation provided by the clinicians, thus essentially down-grading ourcoding and reimbursement?

REMEMBER THE INTENT OF THE ORDER….



Per the AMA – Inquiry Question: When the nursing department fails to document a stop time for an

infusion how should this be reported? Since we cannot determine thetime component is it appropriate to default to an IVP?

From a CPT coding perspective, as with other CPT time-based codes(eg, physical medicine), to accurately describe the service(s) performed,the medical record documentation must reflect the time interval involved.

The Introduction of the CPT codebook specifies “Do not select a CPTcode that merely approximates the service provided”. Therefore, itwould not be appropriate to default to a lesser or greater therapeuticinfusion/injection code.

The circumstance described in your inquiry is more a documentation andcompliance question wherein facility-approved protocols sufficient toprove a good faith effort at correct coding should be followed.



Without documented time; should you default to IVpush(es)?

Nurse A/Patient A may understand the rules of properdocumentation of hydration services along with time up andtime down90760 and 90761 are correctly submitted and reimbursed

national payment $114.00 per hour, $25.00 additionalhour(s) with co-beneficiary responsibilities.

Nurse B/Patient B, same day, different patient - may not havegood documentation skills -Lacking the hydration down time - therefore based on the

instruction reporting 90774 or IV Push with national APCpayment of $51.00 with co-beneficiary responsibility.



Patient A co-beneficiary responsibility is$27.00 (good hydration documentation of 2hours)

Patient B co-beneficiary responsibility is$10.24 (bad documentation due to lack oftime down or infusion time frame)

Based on the example above, the facility hasjust charged the same service differently tothe beneficiaries thus potential complianceissue.


IM/SQ InjectionsIM/SQ Injections Same drug/different drug does not impact code reporting – can be reported as

many times ordered and given with proper documentation Answer verified in Q/A 22; AHA Coding Clinic for HCPCS, Third Quarter, Volume 6,

Number 3. Verified by the AMA – CPT Knowledge Base

Do not report 90772 for Td injection; correct code 90471 Mandate documented abbreviations – IM, SQ Brackets – Understand the meaning behind “bracketed” injections; do not make

assumptions that they are mixed. Work with clinical staff to understandabbreviations and meanings

Investigate Self Administered Drugs (SAD) to include Insulin and Lovenox Noridian’s Ruling – “If SAD; then route of administration non-covered.”

Q25 We bill the patient the self-administered drug under revenue code 637. Can wealso bill the patient for the drug administration (IM/subcutaneous injection forinsulin) under revenue code 637?A25 If the drug is non-covered, administration of that drug is also non-covered.

Do not report modifiers 76 or 77 Appropriate modifier 59, if applicable


IM/SQ InjectionsIM/SQ Injections

When administering a drug subcutaneously and the dose to beadministered exceeds the volume that can safely be injected ata single site requiring multiple injections in order to achieve therequired dose, would each of the injections be codedseparately or would a single unit be billed for the injection?

ANSWER - If the drug/substance is prepared one time andadministered in four portions, the administrations should berecognized and reported as one administration?

However, multiple administrations that are prepared individuallyshould be recognized and reported as individualadministrations. Therefore, if four separate injections wereprepared and individually administered as four separateinjections.


Multiple Push Injections of theMultiple Push Injections of theSame DrugSame Drug

Question: Can multiple IV push injections of the samedrug/substance be reported?

Answer: Yes, now that we have the NEW CPT code+ 90776 - Therapeutic, prophylactic or diagnostic injection(specify substance or drug); each additional sequentialintravenous push of the same substance/drug provided in afacility (List separately in addition to code for primaryprocedure)

Time requirements state - Do not report 90776 for a pushperformed within 30 minutes of a reported push of the samesubstance or drug AMA states – “if prepared one time and administered in

portions/fractions it is recognized and reported as oneadministration or 90774”

“If multiple administrations that are prepared individually shouldbe recognized and report as individual administrations.”


Multiple Push Injections ofMultiple Push Injections ofthe Same Drugthe Same Drug

Patient presents for IV push Demerol @ 10 am, IV pushMorphine @ 10:30 am and IV push Demerol mixed withPhenergan @ 11 am. How would this be coded utilizingthe 90776 code for facilities?

First two IV pushes in separate syringes, however lastpush mixed with NEW drug and SAME drug.

Is it appropriate to report - ???? 90774 first drug - Demerol, 90775 new drug - Morphine, 90775 new drug (Phenergan) and 90776 (Demerol)

(same drug but 1 hour apart from initial push)


Multiple Push Injections ofMultiple Push Injections ofthe Same Drugthe Same Drug

There are three individual IV pushes being performed. CPT code90774, Therapeutic, prophylactic or diagnostic injection (specifysubstance or drug);intravenous push, single or initial substance/drug,should be reported for the IV push of Demerol.

CPT code 90775, Therapeutic, prophylactic or diagnostic injection(specify substance or drug); each additional sequential intravenouspush of a new substance/drug (List separately in addition to code forprimary procedure), should be reported for the IV push ofMorphine.

CPT code 90775 should also be reported for the IV push of theDemerol and Phenergan mixed in the same syringe.

To clarify this reporting, multiple administrations that are preparedindividually should be recognized and reported as individualadministrations. Technically, if two drugs are mixed in a syringe foradministration via IV push, it would constitute one IV push. To furtherclarify, if the drug or substance is prepared one time and administeredin two or three portions, the administrations should be recognized andreported as only one administration (eg, 90774 not 90774 x1 and90775 x1 nor 90774 x1 and 90775 x2).


IV Piggy Back (IVPB)IV Piggy Back (IVPB) Abbreviations and start/stop times cannot be emphasized enough!! Patient presents to ED for alcohol ingestion and physician orders .9

NS @ 250 cc per hour and adds into the NS a piggyback of multi-vitamins 10ml. 1000 ml INTAKE @ 250 per hour. Would this infusionbe considered hydration or therapeutic?

the therapeutic, prophylactic, or diagnostic IV infusion codes (90765,90766) should be reported for the administration of substances/drugs.In this instance the substance infused is the 10 ml of multi-vitamins inthe liter of 0.9% normal saline. Based on the time interval provided,therefore, the first hour of infusion is reported using code 90765,Intravenous infusion, for therapy, prophylaxis, or diagnosis (specifysubstance or drug); initial, up to 1 hour. Add-on code 90766,Intravenous infusion, for therapy, prophylaxis, or diagnosis (specifysubstance or drug); each additional hour (List separately in addition tocode for primary procedure) is reported three times (once for eachadditional hour of infusion).

The hydration codes 90760-90761 are not used to report infusion ofdrugs or other substances.


IV Piggy Back (IVPB)IV Piggy Back (IVPB)““Exception and CaveatException and Caveat””

RETAVASE is administered via unique double-bolusadministration. Two 10-unit IV bolus injections are required fora complete treatment two min per bolus & administered 30 minapart. Would this qualify for 92977 by intravenous technique?

CPT code 92977,Thrombolysis, coronary; by intravenousinfusion, is reported when intravenous infusion of athrombolytic agent is administered by the physician.

The descriptor nomenclature specifies the work and intensityassociated with coronary thrombolysis, code 92977,Thrombolysis, coronary; by intravenous infusion, mostaccurately describes the procedure performed for Retavaseadministration.


IV Piggy Back (IVPB)IV Piggy Back (IVPB) Patient admitted to OBSV and physician orders Ciprofloxacin (Cipro)

IVPB over 1 hour every 8 hours. Patient receives first dose from 10 -11 am and next from 7 pm -8 pm. How would this be reported?

Code 90765, Intravenous infusion, for therapy, prophylaxis, ordiagnosis (specify substance or drug); initial, up to 1 hour, should bereported for the first intravenous infusion of the antibiotic (Cipro) andcode 90767, additional sequential infusion, up to 1 hour (Listseparately in addition to code for primary procedure) should bereported to reflect the second Cipro infusion.

The rationale for reporting both codes 90765 and 90767 relates to theuse of these codes wherein only one initial service code should bereported per IV site per encounter. The observation stay for that datewould be considered a singular encounter, for which 90765 and 90767are reportable.


IV Piggy Back (IVPB)IV Piggy Back (IVPB) Heparin 6000 units IVP given or bolus; then continued infused

to start @ 1500 units/hour. Can I report 90765 and 90775 foreach service when documented appropriately with time?

In the clinical setting to Heparinize a patient a larger dose isadministered by what is commonly known as “bolus” with amaintenance dose either by an IM or IV regiment to follow.Two separate doses of Heparin are administered and thenadministered the 1500 units/hour of Heparin.

Two separately prepared administration services or IV pushes90775 (will depend on time and 30 minute requirement for90776) and 90765, 90766 for the IV solution for the infusion ofHeparin.


HydrationHydration

Question: Is a diagnosis of dehydration required to reporthydration CPT codes 90760 and/or 90761?

CPT did not explicitly outline documentation requirements related toutilization of the hydration codes. If hydration is ordered by aphysician, medical necessity is assumed. The clinical scenario woulddrive the ordering.

Documentation of the service itself (ie, hydration, therapeuticinfusion) occurs simply by recording the provision of the hydration.Support for the hydration/therapeutic infusion service is associatedevaluation and management service code(s) performed usually on thesame day by the same provider. Typically, this involves whateverclinical assessment that gives cause of the dehydration or thepatient’s inability to take fluids with the physical assessment and/orlaboratory testing/results supporting this status.


HydrationHydrationQuestion: Does there have to be a certain rate in order

to confirm medical necessity?No, but a valid order for hydration is required.

There are many reasons and different diagnoses that may warrantan order for hydration, including diarrhea, nausea, vomiting, pain,dehydration, etc.A specific rate alone does not necessarily point to hydration. ANSWER – CMS has adopted the definition of services and applied

these definitions whenever possible. CPT does not distinguish bythe # of cc’s per hour.CPT defines hydration based on the solutions (pre-mixed, D5-W, .9

normal saline, pre-mixed electrolytes, lactated ringers, etc.)Hydration CPT codes cannot be reported for KVO, heplock/ saline

lock


HydrationHydration If a patient receives several boluses of normal saline over a period of

time with a KVO between boluses, do I add the time of the boluses togive me the hydration time? Note, all of the boluses last 15 min orless. BOLUS - A large volume of fluid or dose of a drug givenintravenously and rapidly at one time.

Basically, what is happening here is that the IV rate is being adjustedto infuse lots of fluid over a brief period of time, then essentially none(KVO time). This is better described as hydration, albeit in an unusualfashion, but not sequential IV pushes/brief infusions. The IV is neverremoved. Usually, the same bag of fluid is utilized (unless it is usedup and replaced by a second, etc.)”

Since the scenario provided indicates the three fluid boluses wereadministered for 15 minutes or less, the hydration code 90760,Intravenous infusion, hydration; initial, up to 1 hour should beappropriate based on the infusion time interval involved.


HydrationHydration Problematic units –

Problematic “RTP” with the following 90761 with greater than 8 units Reason 31715 – excess units of service

FI stated Issue with grouping logic on their end. Wait 2 weeks and re-submit

Immediately investigate your “shop” to see what is happening Discuss with your FI to determine when “fix” will be implemented Determine how additional hour(s) of hydration or 90761 will be

reported overall calendar days or OBSV Open Door Forum stated –

If the outpatient encounter continues over one or two days, treat it asone encounter or episode.

Report all charges for OBSV hour(s) and infusion services using theadmitting date

Be sure to verify claims after January 1st to ensure proper grouping andpayment.


HydrationHydration

Question - If a patient is infused with saline concurrently, withan infusion of a non-chemotherapy drug , can hydration bebilled separately?

Answer – Hydration can only be billed separately if it is givenprior or subsequent and is greater than 30 minutes. If hydrationfluid is provided to facilitate drug delivery then it is consideredincidental to that infusion and is not separately billable. (CCIManual)

Answer - Administration of fluid during a transfusion orbetween units of blood products to maintain IV line patency isincidental hydration and is not separately reportable. (CCIManual)


Concurrent versusConcurrent versusSequentialSequential

Main Definitions – CONCURRENT SIMPLIFIED - Multiple infusions are provided

through the same intravenous line defined by the AMA. Concurrent Infusion – in order to report CPT code 90768, the

drugs cannot simply be mixed in one bag; there must be morethan one bag. If the drugs are mixed in the same bag, then report only

the initial infusion code (i.e. 90765) If the drugs are being infused at the same time in two

different bags, then an initial infusion code (i.e. 90765)and the concurrent (i.e. 90768) should be reported

FYI – under OPPS 90768 is a packaged service A concurrent infusion or 90768 can be billed once per

patient encounter and is not a time based code. Do not reported 90768 for incidental hydration or fluid

utilized to move drug through system.



Antibiotic A infused from 10 AM - 1 PM and Antibiotic B infusedfrom 11 AM - 2 PM - running concurrently. How would this bereported - the entire length of the infusion which would be 10 - 2equals 90765 and 90766 with 3 units plus 90768 to representconcurrent? OR is there another way of capture this infusion event?

The initial service is the intravenous infusion of Antibiotic A (nothydration and not chemotherapy). The next service is thesimultaneous intravenous infusion of Antibiotic B. The followingcodes should be reported:

90765 for the initial one-hour infusion of Antibiotic A90766 x2 for the additional two-hour infusion interval for Antibiotic A90768 is reported ONCE (regardless of the infusion interval involved)for the concurrent infusion of Antibiotic B



Main Definitions –SEQUENTIAL SIMPLIFIED – One drug

after anotherAn infusion of a different drug

immediately following the initial drugClinicians must clearly document the time

each drug was put up for the patientand what time the infusion ended


Monoclonal Antibody TherapyMonoclonal Antibody TherapyBiological Response ModifierBiological Response Modifier““MAB/BRMMAB/BRM””

2008 DEFINITION2008 DEFINITION - Chemotherapy administrationcodes 96401 through 96549 apply to parenteraladministration of non-radionuclide anti-neoplastic drugs; and also to anti-neoplasticagents provided for treatment of noncancerdiagnoses (eg, cyclophosphamide for auto-immune conditions) or to substances such asmonoclonal antibody agents, and other biologicresponse modifiers.

No list available via CMS or FI Case-by-case determination with drug and DX Contact your FI to determine code reporting


Monoclonal Antibody TherapyMonoclonal Antibody TherapyBiological Response ModifierBiological Response Modifier““MAB/BRMMAB/BRM””

Epogen (Epoetin Alfa) Injection – 90772

Lupron Injection – 96402

Neulasta or Neupogen – 90772

Xolair (Omalizumab) - 90772


ChemotherapyChemotherapy

Hydration and Chemotherapy Medically necessity to hydrate before or after chemotherapy

administration Hydration must be greater than 30 min provided as

secondary or sequential service Separate payment is made for hydration therapy provided

sequentially, but not concurrently to chemotherapy infusion Background solution that runs concurrently with chemotherapy

as a mode to transport or facilitate drug is integral to theprocedure; do not report hydration separately

To indicate hydration was administered sequentially, that isbefore or after chemotherapy report 90761 to identify hydrationwas no furnished concurrently with chemotherapy 96413

Service only to provide hydration in the AM and another sessionin the PM – report second session with Modifier 59


ChemotherapyChemotherapy Anti-anemia and anti-emetic drugs and chemotherapy -

Therapeutic fluid administration is medically necessary (eg.correction of dehydration, prevention of nephrotoxicity) before orafter transfusion or chemotherapy, it may be reported separately(CCI Manual)

Medications (e.g. antibiotics, steroidal agents, antiemetics,narcotics analgesics) administered independently or sequentiallyas supportive management of chemotherapy administrationshould be separately reported – (CCI Manual)

90761, 90766, 90767, 90768, 90775, or 90799 as appropriate NOTE: Above codes are ADD-ON codes

Medicare will pay for the drug product (some anti-emetics)Be sure to check your pharmacy CDM and unit

calculation



Leucovorin (WELLCOVORIN J0640) IV runs for 2 hours (0900-1100). During that time, Irinotecan (CAMPTOSAR J9206) runsfor 95 min (0900-1035). We understand that we would bill forthe initial chemo IV infusion (96413, 96415) for the Irinotecaninfusion. How do we bill for Leucovorin infusion? Would it bebilled as concurrent (90768) for the first hour and the last 30min be sequential non-chemo (90767)?

Answer – Irinotencan or CAMPTOSAR is a chemotherapy drugthat was infused from 0900-1035 and billed with 96413, 96415.Leucovorin was also initiated at 0900 -1100.

LEUCOVORIN would be billed as a concurrent NON CHEMOinfusion 90768. A concurrent infusion 90768 can only bereported once per encounter regardless of duration.

If the infusion are not administered concurrently, Leucovorinwould be billed with a NON-CHEMO infusion administrationcode OR 90767 for the first hour.



Patient presents for chemotherapy. Decadron givenfrom 13:15 to 13:45. Liposomal given from 13:55 -15:05 or 96413 x 1. The pre-infusion of decadron -should it be 90767 or 90766 x 1? The notes in theCPT book under 96413 state that 90766, 90767,90775 if administered as secondary or subsequentservice in association with 96413. Under 90767states use in conjunction with 96413 after differentinitial service is performed. Which is correct?


ChemotherapyChemotherapy The primary reason for the encounter is the chemotherapy

administration. The initial service is reported using code 96413,Chemotherapy administration, intravenous infusion technique; up to1hour, single or initial substance/drug.

Since only one initial service may be reported per encounter (whenadministered through the same IV access) the decadron is a differentdrug being administered as a separate sequential infusion (to thechemotherapy infusion). In this instance, the add-on code 90767,Intravenous infusion, for therapy, prophylaxis, or diagnosis (specifysubstance or drug); additional sequential infusion, up to 1 hour (Listseparately in addition to code for primary procedure) is reported inconjunction with the stand-alone code, 96413.

It would not be appropriate to report code 90766, Intravenous infusion,for therapy, prophylaxis, or diagnosis (specify substance or drug);each additional hour (List separately in addition to code for primaryprocedure) as code 90766 is only reported when describing additionaltime intervals greater than 30 minutes beyond the 1 hour incrementsof codes 90765 and 90767.


CPR and InjectionsCPR and Injections CCI Manual Instructions - “In keeping with the policies outlined previously, procedures

routinely performed as part of a comprehensive service areincluded in the comprehensive service and not separatelyreported. A number of therapeutic and diagnosticcardiovascular procedures (e.g., CPT codes 92950-92998,93501-93545, 93600-93624, 93640-93652) routinely utilizeintravenous or intraarterial vascular access, routinely requireelectrocardiographic monitoring, and frequently requirefrequently requireagents administered by injection or infusion techniques;agents administered by injection or infusion techniques;accordingly, separate codes for routine access,accordingly, separate codes for routine access,monitoring, injection or infusion services are not to bemonitoring, injection or infusion services are not to bereported.reported.””

If provided separate and distinct from CPR, modifier 59 wouldbe appended with documentation.

RiverBend published this interpretation Jan-March 2007


PrePre--OperativeOperativeInjectionsInjections

Do not report preoperative injections/infusions – Case inpoint, antibiotics pre-operatively given –

CCI Manual Version 13.3 – Do not report drug administration CPTcodes for injections/infusions related to procedure to includeanesthesia, hydration and medications as anxiolytics andantibiotics.

“Do not report pre injections for other tests = Do not report 90760-90775 or 90779 with codes for which IV push or

infusion is an inherent part of the primary procedure (e.g.administration of contrast material for a diagnostic imaging study.)

FIs mirror the same policy – “If a medication is given because of surgery and is specific to the

patient, the administration charge is considered part of theprocedure charge. The amphoterin would not be given if it werenot for the surgery, and as such, is considered part of the patient’sspecific pre-operative needs. The drug is specific to the patient,but the need for the drug is specific to the surgery, therefore, aspecific infusion charge for the amphoterin is not allowed. Theinfusion is covered in the operating room charges.


Post Operative InjectionsPost Operative InjectionsRecovery/StepRecovery/Step--Down/OBVSDown/OBVSFollowing SurgeryFollowing Surgery

2007 Final Policy from CMS –“Therefore, we are not accepting the

recommendation of the APC Panel topay separately for all IV pushes andinjections for pain management andother clinical conditions. Consistentwith our current payment policy, insome cases their payment ispackaged into payment for theassociated procedures.”

Infusion ConfusionWhat’s Your Solution!!

2008 JOKERS’ WILD EDITION

Infusion ConfusionInfusion ConfusionWhatWhat’’s Your Solution!!s Your Solution!!

2008 JOKERS2008 JOKERS’’ WILD EDITIONWILD EDITION

Presented by:Andrea Clark, RHIA, CCS, CPH - PresidentHealth Revenue Assurance Associates, [email protected]

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Infusion Confusion What’s Your Solution!! 2008 JOKERS ... · Infusion Confusion What’s Your Solution!! ... What’s Your Solution!! 2008 JOKERS’ WILD EDITION Presented by: Andrea