Drug Administration Uglies

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Presented by
Karen Kvarfordt, RHIA, CCS-P, CCDS
President, DiagnosisPlus, Inc.
“Finding HealthCare Solutions…Together”
PO Box 2521Twin Falls, ID 83303(208) 423-9036
[email protected]
 2014
Drug Admin CPT codes and rules
 Same ‘Renumbered’ CPT codes from 2009
 Review clinical scenarios related to some of
these codes
 Review documentation requirements and better
practices
 Time Documentation (start & stop)
 Using Modifier -59 with Drug Administration
Services
2
 Nope,
it isn’t pharmacy. Just revenue,
not cash.
 Nope, it isn’t supplies either. Just
revenue, not cash.
 Yes, it is Nursing! They are finally able
to bill specifically for the services they
provide in an outpatient setting. It’s
about time!
3




High area of lost revenue: ER to OBS,
Direct admit to OBS, and OR to OBS.
Co-mingling inpt and obs beds = highly
problematic time charting for drug
administration.
Focus nursing on charting start and stop
times to capture every minute.
Charge capture is highly complex for nursing.
4

Observation – IV Infusions, Injections, Blood
Transfusions, Outpatient Procedures
 IDEA: Identify an owner to charge capture on the
unit or move to Charge Capture Analyst.
 IDEA: Drug Administration & bedside procedures =
major lost revenue.
 IDEA: Create Observation Attack Team to audit
daily for billable time, G code, and charge capture for
nursing procedures, Condition Code 44 = 1 touch.
5



Initial/primary reason
for visit
Use 9xxxx codes for
all payers. C code/pump
for Medicare only
Once determined,
initial/primary visit
code (hydration,
therapeutic, chemo)then use subsequent
CPTs for additional
services



All outpatient areas are
impacted: ER,
Observation, Hospital
Based Clinics (HBC)
IDEA: Nursing takes
ownership for charting
‘stop and stop’ times per
CPT
IDEA: Create Charge
Capture Analyst position
6




Create a stamp for Drug Adm start and stop times. (Could do
recovery & 02 as they are timed charges)
Use the stamp for billable time
IV Hydration Infusion
______ _______ ______ _____ ______ (multiple
lines)
Start
Stop
Date
Dept Initials
IV Therapeutic Infusion
_____ ________ _______ ______ ______ (multiple
lines)
Start
Stop
Date
Dept Initials
Remember! Time continues from the Emergency Room to the
Observation/Outpatient areas
7

No major changes in OPPS rules
Per-service APC payment continues
Financial impact related to drug administration
services will vary based on your mix of services,
hours of infusion, and internal charge capture
practices

Majority of drug administration changes
due to additional parenthetical notes
8


Need to continue following CPT guidelines and
instructions and MUST review CPT
descriptors and parenthetical notes carefully!
From the hydration, therapeutic,
prophylactic,
and diagnostic injections & infusions section:

“Physician work related to hydration, injection, and infusion
services predominantly involves affirmation of treatment plan and
direct supervision of staff. These codes are not intended to be
reported by the physician in the facility setting.”

Note: The above language was new in 2008… sets precedent regarding
facility vs. physician reporting.
9
• Still the same! CPT has outlined a hierarchy from
Nov 2005 CPT Assistant
 Takes
the guess work out of trying to figure out which
drug admin service should be the “initial”, subsequent,
etc.
• “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.
10

Question: Does the fact that infusions
are primary to pushes mean that hydration
is primary to a push (IV push injection)?
Answer: No, because the first sub-bullet
indicates that therapeutic, prophylactic and
diagnostic services are primary to hydration
services; an IV push is considered a
therapeutic, prophylactic, or diagnostic service,
therefore it is primary to hydration.
11



The CPT statement is: “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.”
Within each “code set” have a further breakdown of
the type of delivery/route/method (infusion, then
the push, then the injection).
Since hydration is the last code set, and there is only
one method (infusion), it would always be secondary
to any other medication administrations.
12
When administering multiple infusions, injections
or combinations, only 1 initial service code should
be reported, unless protocol requires that 2
separate IV sites must be used and is medically
necessary.
If a significant separately identifiable E&M
service is performed, the appropriate E&M service
code should be reported using modifier -25 in
addition to 96360-96379. For same day E&M
service a different diagnosis is not required.
13

If performed to facilitate the infusion or injection,
the following services are included and are not
separately billable:
a.
b.
c.
d.
e.
Use of local anesthesia
IV start
Access to indwelling IV, subcutaneous
catheter or port
Flush at conclusion of infusion
Standard tubing, syringes and supplies
14
 Codes
all deleted and moved in front of the
Chemotherapy CPT codes (renumbered) in
2009 – still the same for 2014
 Same 2014 CPT Codes: 96360 – 96379
 Same Heading:
Hydration, Therapeutic, Prophylactic, Diagnostic
Injections and Infusions, and Chemotherapy and
Other Highly Complex Drug or Highly Complex
Biologic Agent Administration
15


Parenteral administration non-radionuclide
anti-neoplastic
Anti-neoplastic for non-cancer diagnoses
◦ i.e., Cyclophosphamide for auto-immune
conditions

Monoclonal antibody agents
◦ Other biologic response modifiers (BRM)
16

Very complex work and monitoring way beyond a
‘normal’ infusion
◦ Possibility of severe reactions
◦ Advanced practice training
◦ Special consideration for prep, dosage, disposal
◦ Frequent monitoring
 Changes in infusion rate
 Prolonged presence of nurse
 Frequent communication with physician
◦ If performed to facilitate infusion or injection,
these are included and are not separately billable
17
 CPT
96360: Intravenous infusion, hydration;
initial, 31 minutes to 1 hour
 Must

 Do
reach 31 minutes in order to bill infusion
In 2007 we had 16 minutes (history tidbit)
not report hydration infusions of 30 minutes or
less! No CPT code for this!
 Hydration
– IV infusion to consist of a pre-packaged fluid
and electrolytes (i.e. normal saline, D5 ½ normal saline
+30mEq KCL/liter), but are not used to report infusion of
drugs or other substances.
 “TKO” (to keep open) & “KVO” (keep vein open) cannot be
charged.
18
ER patient presents with a laceration
to the forehead
Service
Time
Description
2014 CPT Code
Laceration
repair
5:30
Laceration
repair with
Xylocaine
Depends on
documentation
IVPB
5:00 – 5:20
Normal saline
wide open
No CPT code
IVP
6:00
Morphine
96374 x 1
Blood
transfusion
7:00 – 9:30
Transfusion
2 units whole
blood
36430 x 1
P9010 x 2
19

CPT 96361: Intravenous infusion,
hydration; each additional hour
List separately in addition to code for
primary procedure)
Add-on code (+)
20
 CPT
96365: Intravenous infusion, for
therapy, prophylaxis, or diagnosis; initial, up
to 1 hour
 CPT
96366: Intravenous infusion, for
therapy, prophylaxis, or diagnosis; each
additional hour
List separately in addition to code for primary
procedure).
Add-on code (+)
21
 CPT
96367: Intravenous infusion, for
therapy, prophylaxis, or diagnosis; additional
sequential infusion, up to 1 hour
List separately in addition to code for primary
procedure
Coding Tip! Do not report more than once
per sequential infusion of the same mix.
22
 CPT
96368: Intravenous infusion, for
therapy, prophylaxis, or diagnosis;
concurrent infusion
List separately in addition to code for
primary procedure
23

CPT 96369: Subcutaneous infusion for therapy or
prophylaxis (specify substance or drug); initial, up to
1 hour, including pump set-up and establishment of
subcutaneous infusion site(s).
 CMS Guidance: For infusions of 15 minutes or less, report
with CPT code 96372
 Additional guidance:
Involves the placement of multiple subcutaneous accesses to
infuse immune globulin
 Includes an infusion pump to administer the infusion

24
 CPT
96370: Subcutaneous infusion for
therapy or prophylaxis (specify substance or
drug); each additional hour
List separately in addition to code for primary
procedure
Add-on code (+) = Must be reported with CPT
code 96369
For infusions greater than 30 minutes beyond one
hour increments
25
 CPT
96371: Subcutaneous infusion for
therapy or prophylaxis (specify substance or
drug); additional pump set-up with
establishment of new subcutaneous infusion
site(s).
Report with CPT code 96369
Report 96371 only 1 time per day
CMS Guidance: “Captures the practice expense of
obtaining additional accesses and the set up of a
pump for infusions in larger individuals”.
26
 CPT
96372: Therapeutic, prophylactic or
diagnostic injection; subcutaneous or
intramuscular (SC/SQ or IM)
 Only
CPT code that does NOT follow the CPT
hierarchy – rules do not apply
 Can
report multiple SC/SQ/IM injections of
the same substance/drug
27
 CPT
96373: Therapeutic, prophylactic
or diagnostic injection, intra-arterial
 CPT
96374: Therapeutic, prophylactic
or diagnostic injection; IV push, single
or initial drug
28
 CPT
96375: Therapeutic, prophylactic or
diagnostic injection; each additional
sequential IVP of a new substance/drug
List separately in addition to code for primary
procedure
Add-on code (+)
96374 + 96375
29
 CPT
96376: Therapeutic, prophylactic or
diagnostic injection (specify substance or drug);
each additional sequential IV push of the same
substance/drug provided in a facility
Be careful! Code cannot be reported if a push of the
same substance or drug occurred within 30 minutes
(pushes of same substance or drug must be “31
“minutes apart)

Ex: Four hourly IVPs of Demerol would be reported as 96374 x
1 & 96376 x 3 as long as the time requirement is met
Is the time documented in your medical record?
30
multiple individually prepared
administrations as individual drug
administrations.
 If the drug or substance is prepared one time
and then administered in portions, report the
administrations as only one administration (i.e.
CPT 96374).
 If the clinician administers a 2nd, separately
prepared same drug in portions, this would
equal a single admin of the same drug beyond a
30-minute interval (CPT 96376).
 Report
31
Medical record documentation by the
clinician does not easily allow a coder to
determine whether the IV pushes were
individually prepared or administered in
portions.
 Still no separate APC payment assigned
to this code for 2014.

32
Service
Time
Description
2014 CPT Codes
IVP
1000
Lasix
96374 x 1
IVP
1110
Lasix
96376 x 1
IVP
1300
Lasix
96376 x 1
IVP
1500
Lasix
96376 x 1
33
Service
Time
Description
2014 CPT Codes
IVP
1000
Lasix
96374 x 1
IVP
1018
Lasix
No code – Why?
IVP
1300
Lasix
96376 x 1
IVP
1500
Lasix
96376 x 1
34

Initial
Code that best describes the key or primary reason for the
visit
 One code in each category of IV infusion and IV push drug
administration codes has been designated as the “initial”
service
 Order of service delivery does NOT determine what is
“initial”
 Only one “initial” service should be reported per encounter
UNLESS:

 Protocol requires two separate IV sites
 Multiple encounters are provided on the same DOS
 Other drug administration services are also provided by a
different route other than IV infusion or IV push
35
Question: How is the initial service selected?
 Answer: The “initial” code that best describes the
key or primary reason for the encounter should
always be reported regardless of the order in which
the infusions or injections were given.
This was not always clear in the past, but now the
2014 CPT book makes it explicit with a hierarchy!

 Chemo infusions
 Chemo injections
 Non-chemo, therapeutic infusions
 Non-chemo, therapeutic injections
 Other injections
 Hydration infusions
36

Sequential/Subsequent
Add-on codes (think “one after another” or
“before or after the initial drug service”)
 Should be used in addition to an “initial” code
and the order of the services given does not
matter
 Reported once per encounter for the same
infusate mix; additional hours reported with
additional hours therapeutic infusion code
(96366); and it is okay to report multiple
sequential infusion codes if multiple different
drugs are given
 Infusion must be 16-91 minutes…apply the
infusion time requirement
37


Question: How should an IV infusion of the
same infusate that’s given multiple times
during 1 visit be reported?
Answer: For example, calcium and magnesium
are combined with D5W in an IV bag and one
20 minute infusion is given pre-chemo and one
20 minute infusion is given after chemo. This
infusion would be billed as one sequential
infusion, up to 1 hour (96367). The two 20minute infusions of calcium/magnesium would
be added together for a total of 40 minutes.
38
 Concurrent
(think “at the same time”)
Add-on code when multiple infusions are provided
simultaneously through the same IV line, even with
different bags.
No code for concurrent administration of chemo
drugs, but if it does happen, then the unlisted
chemo admin code 96549 should be reported.
Multiple substances mixed in one bag are
considered to be one infusion, not a concurrent
infusion.
There is no concurrent code for hydration.
Still no separate payment for the concurrent
infusion code (96368) for 2014.
39
If a separate venous access site is started for
hydration along w/ another venous access site for a
therapeutic infusion, report an “initial” code for the
hydration and the appropriate “initial” code for the
other infusion access site.
 However, the CPT Manual makes it clear that
hydration running concurrently through the same
access site is still not separately reportable.

40

Selecting what the “initial” service is less of
a mystery now! Yeah!
 Fairly
easy for scheduled clinic/infusion therapy
and oncology patients.
 Not as easy for unscheduled/ER visits so follow
the hierarchy & read the CPT parenthetical notes.
 Remember, hydration can be reported with other
drug admin services, but it will typically not be
reported with the “initial” service code.
 Can’t always rely on an edit to tell if what you are
charging/coding is correct or incorrect.
41



IV infusion of short duration is still defined
as 15 minutes or less - report with an IV push
injection code.
Initial or 1st hour of infusion is from 16 to 90
minutes (applies to therapeutic infusions but
not to hydration).
Additional hours of infusion
Report add-on codes for additional hours of
infusion (beyond the 1st hour) only after more than
30 minutes have passed from the end of the
previously billed hour (i.e. 91 minutes would allow an
additional hour to be charged).
42
Per AMA – “Infusion time is measured when the
infusate is actually running: pre and post time are not
counted. It is recommended to document BOTH
infusion start and stop times.”
 Per CMS – “Hospitals are to report codes according to
CPT instructions. Are to use the actual time over which
the infusion is administered to the patient for timespecific drug administration codes.”
 Remember that a reviewer must be able to determine
the actual amount of time a medication infused from
the records, not just the ‘ordered’ infusion time.

43

Do you report an infusion, injection, or nothing
when the stop time is missing?
CMS has stated that a short-duration infusion (i.e. less than 15
minutes) can be reported as an IV push injection……. therefore,
if there is no stop time, would the infusion automatically be 15
minutes or less……since you don’t know if it was more?
 CMS does not state anything about what can/cannot be reported
if an explicit “stop” time is missing…..but several FIs have
indicated that an IV push injection can be reported.
 Remember, if there is no stop time for hydration you cannot
report anything unless 30 minutes is charted.

44
 Better
practice is to require start and stop
times for all drug administration services!
 Regardless of how the charges are created,
nursing's charting of start & stops does not
change.
 Financial impact of “down-coding”
CPT 96365 & 96366

National APC payment
CPT 96374 & 96375
$129 (1st hour infusion) vs. $36 (IV push)
 Plus potential loss of any additional hour(s) @ $25
per hour

Makes a huge difference to the bottom line!
45

If the drug administration service is typically
performed pre- or post-procedure, then you do not
separately report.
Examples: Infusion of anesthetic for surgery; pre-op antibiotic
injection/infusion; post-op pain and/or nausea injections;
injections during CPR; injections for sedation analgesia

If the drug administration services is not typical for
the procedure, then you do report it separately.
Examples: Anti-thrombolytic injection either pre- or postsurgery; anti-hypertensive injection
46



ER to OBS
◦ Handoff from ER to OBS – Do you maintain 2
separate nursing documentation tools? Are the
drug administration services being captured
correctly from the ER to OBS?
PP (Post-Procedure) to OBS
◦ Cannot bill observation until 4-6 hours of
routine recovery has passed
Direct Admit to OBS
◦ Nursing needs to document all drug
administration services as well as any bed-side
procedures
47

Modifier -59 must be used in specific
situations and you may find that you are using
them more frequently than what was initially
expected.
Use Modifier -59 if two vascular access sites are
started
Use Modifier -59 if multiple encounters occur on
the same date of service
CCI edits for drug admin are being applied in full,
therefore the traditional rules for modifier -59 are
in effect; no code pairs are exempt from the CCI
edits
48

Most frequent CCI edit: When two initial service codes
are paired together you will receive an edit message:
“Code 96365 is a component of code 96413 but a
modifier is allowed in order to differentiate between
the services provided.”
You can only have one “initial” service per IV site per
encounter unless multiple lines are started.
Just because the edit appears does not mean you
should add it just to get it out the door!
HIM department should be the ones to research WHY
there was a rejection. NEED THE MEDICAL RECORD!
49
What happens when the visit crosses the midnight hour?

On the January 2008 Open Door Forum call, CMS
indicated that multiple “initial” service CPT codes
should not be reported for a single encounter, even if
the encounter crosses dates of service.
Do not “reset” the initial service CPT definitions just because
the encounter has crossed the midnight hour.
Example: If a patient is in the ER on 4-10-13, and IV hydration
is started @ 10:00pm and continues until 4-11-13 @ 2:00am,
how would this look?



96360 x 1 on 4-10-13
96361 x 1 on 4-10-13
96361 x 2 on 4-11-13
50



2014 should be easier since very little has
changed. Just look for further guidance in
the parenthetical notes!
Only sure way of knowing how you are doing
with reporting drug administration services is
to conduct an audit. Measure compliance!
Audit and monitor your records now for
success in 2014! It’s never too late!
51

2014 OPPS Final Rule
www.cms.hhs.gov/HospitalOutpatientPPS/HORD

2014 CPT Book
52
Karen Kvarfordt, RHIA, CCS-P, CCDS
President, DiagnosisPlus, Inc.
P.O. Box 486
5486 Country Club Drive
Pocatello, ID 83204
(208) 221-5486
Fax: (360) 234-7590
[email protected]
www.arsystemsdayegusquiza.com
53
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