Injection & Infusion Confusion
No More!
February 18, 2014
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G2N’s Mission
We work to ensure America’s healthcare
providers have honest & healthy
p
y bottom lines in
order to continue to fulfill their mission of
p
g community
y health.
improving
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Jennifer Kennebeck, MBA, RHIA, CCS
Jenny is Senior Client Partner, Operations for G2N,
Inc G2N provides coding,
Inc.
coding chargemaster and other
revenue cycle consulting services.
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Jennifer Kennebeck, MBA, RHIA, CCS
• Jenny has been a coder for over 20 years, working through all
types of coding and coding management ultimately ending up in
th revenue cycle
the
l and
d on chargemaster
h
t tteams
S in HIM from
o S
SLU;
U; MBA from
o Fontbonne;
o tbo e; C
Credentialed
ede t a ed as a
an
• B.S.
RHIA and CCS
• B
Background
k
d iin llarge system
t
h
hospitals,
it l with
ith experience
i
iin allll ffacets
t
of the revenue cycle
• Joined G2N in 2002
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Agenda
By the end of the hour, you’ll know:
Why we have to learn I / I…
How to correctly
y charge
g for I / I…
Some simpler ways to make it happen…
happen
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Polling Question #1
Have you attended and injection / infusion training
i the
in
th past?
t?
A. Yes,, one
B. Yes, more than one
C Yes
C.
Yes, and there aren’t
aren t enough to make me
understand this!
D No
D.
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Regulations and Guidelines
• Beginning CY 2007 hospitals instructed to use full
sett off drug
d
administration
d i i t ti codes
d ffor billi
billing iin
outpatient departments
• Hospitals must report codes:
- in a manner consistent with descriptors
g CPT instructions
- following
- following correct coding principals
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RAC Impact
Medical documentation may be requested to process
an outpatient claim for IV therapy
therapy.
The request may include:
physician’s
h i i ’ orders,
d
current progress notes,
the IV administration record
record.
(Recovery Audit Contractors review IV hydration–Data
hydration Data Mining)
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CMS Regulations
• When used to facilitate an injection or infusion the
following are not separately reimbursable:
• local anesthesia
• IV starts including access to an indwelling catheter or
port, tubing, syringes and other supplies
– (saline locks, or port flushes done with infusion are not
procedures,, not separately
p
p
y charged)
g )
• preparation of a chemotherapeutic agent
(Medicare Claims Processing Manual
Manual, Pub
Pub. 100-04
100-04, chap
chap. 4
4, sec
sec. 230
230.2
2 [trans
[trans. 902
902, April 7
7, 2006])
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Injections and Infusions
• Documentation (the source document)
• Capture of Charges Rules
– Apply hierarchy
– Episode of administration
– Calculate time units
• Substance, Route,
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Hi
Hierarchy
h & Definitions
D fi iti
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Substance
• Chemotherapeutic Drug
• Therapeutic
Th
ti D
Drug
– antibiotics, steroids, antiemetics, narcotics, analgesics, chemo
adjuvants
j
• Hydration
– Pre-packaged
p
g fluids and electrolytes
y
• normal saline, D5-1/2 normal saline + 30mq KCl/liter)
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Route
CPT Definitions:
– Injection: the act or an instance of injecting a therapeutic
drug into a vein or artery lasting less than 16 minutes
– Infusion: the introducing of a therapeutic drug especially
g longer
g than 15 minutes
into a vein or arteryy lasting
– Hydration – the introducing of a pre-packaged fluid /
electrolytes into a vein or artery lasting longer than 30
minutes
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Substance Definitions
Chemotherapy
– Non-radionuclide anti-neoplastic agents
– Anti-neoplastic agents as treatment for
g
((cyclophosphamide
y
tx for
noncancerous diagnoses
autoimmune condition)
– Biological response modifiers, monoclonal
antibodies
• May require advanced practice training
• Significant risk to patient and frequent monitoring
• Requires special handling for prep and disposal
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Substance Definitions
Therapeutic Drugs/Substances
– Drugs – antibiotics,
antibiotics analgesics
analgesics, antiemetic
antiemetic,
narcotics etc.
– Include K-Riders
K Riders
– “Banana Bags”
– May require advanced practice training
– May require special handling for prep and
disposal
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Substance Definitions
Hydration
– Packaged fluids and electrolytes
For example:
– Normal Saline
– D5-1/2 normal saline + 30mEq KCl/liter
– No special prep or disposal
– May not require advanced practice training
– Typically lower risk to patient
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CPT Terminology
Initial service is:
– first in hierarchy of substance and route of
administration
• not first in time
• not necessarily the primary reason for the encounter
– charged only once per access site
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CMS Regulations
Only one initial drug administration service per
encounter
t for
f each
h vascular
l site
it is
i allowed,
ll
d
regardless of the types of infusion services
provided.
provided
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CMS Regulations – 2 initials
Site 2
Site 1
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CPT Terminology
• Additional hour of infusion – must be the same
drug administered after the first hour of infusion and
continuing a minimum of 31 additional minutes
• 91 – 120 minutes of a drug or chemotherapeutic
substance
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CPT Terminology
Sequential infusion or injection – one after the other
– Example: infusion of Demerol followed by
i f i off Phenergan
infusion
Ph
– Applies
A li tto th
therapeutic
ti iinfusion
f i and
d iintravenous
t
injection (IVP)
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Terminology
Concurrent infusion – therapeutic services
administered simultaneously
– Is not used when hydration is the concurrent
service
– Must be more than one bag, syringe or pump
used
– Report only once per encounter
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Injections and Infusions
• Route of Administration (by Hierarchy)
– Intravenous
I t
(IV)
– Intravenous Push (IVP)
– Subcutaneous (SQ) / Intramuscular (IM)
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Injections and Infusions
Absolute Documentation Requirements:
– Access:
A
• Anatomic Site, including laterality (LFA, RAC)
• Can number sites for ease of documentation
– Duration of administration
• Start time
• Stop time
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Injections and Infusions
• Episode of services:
- Initial
I iti l
- Additional
- Subsequent
- Concurrent
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Injections and Infusions
• Duration of administration – Time
– Infusion • IV administration of a drug greater than 15 minutes
• First hour of initial drug infusion must last 16 minutes
t charge
to
h
one hour
h
• All subsequent infusions of the SAME DRUG (after the
initial) must last a minimum of 31 minutes to charge an
additional hour
• Report additional infusions through the same vascular
site using the sequential, concurrent, or additional
hours charges
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Injections and Infusions
• Each hour of infusion time may only be charged
once unless there are multiple access sites
Example: Drug 1
RFA
Drug 2
LFA
Hydration
yd at o LFA
IV
IV
IV
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10:43
10:44
09:15
09
5
11:51
11:51
11:51
5
28
Injections and Infusions
• Intravenous Push (IVP)
– Drug administration time less than 16 minutes
• Infusions without a documented start and stop time must be
charged as IVP injections
• Reimbursement impact: approximately $65 less for
Medicare patients (could be more on a charge-based
payer)
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Injections and Infusions
• Multiple IVPs of the same drug must have a
minimum of 31 minutes between charged
administrations
Example: Demerol
Demerol
Demerol
D
Demerol
l
IVP
IVP
IVP
IVP
RFA
RFA
RFA
RFA
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12:02
12:18
12:32
13 06
13:06
30
Time Increment Summary
• Chemo & Therapeutic
– Initial – must infuse 16 minutes or more
– Additional – after 91 minutes, (60 + 31 minutes)
– Sequential- New drug 16 or more minutes
– ConcurrentC
t infusing
i f i same site,
it same time
ti
• Hydration
– Initial hour – Must infuse at least 31 minutes
– Additional hours – after 91 minutes, (60 + 31
minutes)
• IVP, multiple of same drug
– Must have 31 minute interval between injections
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Injections and Infusions
All Hydration hours must be administered for a
minimum of 31 minutes in order to charge one
hour of administration
Flush of an access is not charged and considered
part of the administration
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Polling Question #2
Who is responsible for injection and infusion
charging in your facility?
A.
B.
C.
D.
HIM
PFS / Patient Accounts
Clinical Area
We aren’t capturing them
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Hierarchy - Review
Hierarchy
1 Ch
1.
Chemo
a. IV
b IVP
b.
2. Therapeutic Drug
a. IV
b. IVP
3. Hydration-IV
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Documentation - Review
• Documentation of administration must have the
following:
– Substance
– Route
R t off administration
d i i t ti
– Access Site
– Start
St t Time
Ti
– Stop Time
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Warm-Up 1
Assume one IV site on all examples unless
indicated otherwise
NS
1340 – 1445
A
Answer:
-65
65 minutes
i t off hydration
h d ti
-96360 (hydration, initial hour)
-additional
additional hour must be at least
31 minutes
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Warm-Up 2
NS
MSO4
Answer:
IV
IV
0730
1045
96374 (IV Push 1st/only drug)
no stop time on NS=no code
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Ch ll
Challenges
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Challenge 3
Levaquin
Digoxin
Propofol gtt
Dopamine gtt
Zosyn
Levofed gtt
IV
IV
IV
IV
IV
IV
1630 – 1814
1657
1707 – X
1805 – 1837
1818 – 1839
1838
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Challenge 3
Levaquin
Digoxin
Propofol gtt
Dopamine gtt
Zosyn
Levofed gtt
IV
IV
IV
IV
IV
IV
1630 – 1814
1657
1707 – X
1805 – 1837
1818 – 1839
1838
96365, 96366 (104 minutes)
96375
96375 (no stop time)
96367 (22 minutes)
96368 (overlap 19 / 2 minutes leftover)
96375
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Challenge 4
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Challenge 4
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Challenge 4
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Challenge 4
Chemo infusion Avastin
Non-chemo IVP Aloxi
Non-chemo IM injection Procrit
Non-chemo IVP Decadron
Chemo infusion Alimta
Chemo infusion Carboplatin
N
Non-chemo
h
iinfusion
f i Zometa
Z
t
0915 - 0945
0915
0925
1001
1005 – 1024
1030 – 1100
1110 – 1120
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Challenge 4
Answer:
Chemo infusion Avastin
Non-chemo IVP Aloxi
Non-chemo IM injection Procrit
Non-chemo IVP Decadron
Chemo infusion Alimta
Ch
Chemo
iinfusion
f i C
Carboplatin
b l ti
Non-chemo infusion Zometa
0915 - 0945
0915
0925
1001
1005 – 1024
1030 – 1100
1110 – 1120
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96413
96375
96372
96375
96417
96417
96375
46
Polling Question #3
Do you document stop times on all infusions
now?
A.
B
B.
C.
D.
Yes, on outpatients
Yes on inpatients
Yes,
Yes, on inpatient and outpatient
No
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Challenge 5
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Challenge 5
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Challenge 5
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Challenge 5
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Challenge 5
NS 250ml
N
Non-chemo
h
IVP Lasix
L i
Chemo infusion Avastin
yp
Chemo infusion Oxyplatin
Non-chemo infusion Leucovorin
Non-chemo IVP Lasix
Chemo infusion 5FU
Chemo infusion 5FU
0935 – 1245
1031
1101 – 1233
1250 – 1510
1250 – 1510
1540
1525 – 1539
(over 46 hours)
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Challenge 5
Answer:
NS 250
250mll
Non-chemo IVP Lasix
Chemo infusion Avastin
Chemo infusion Oxyplatin
Non-chemo inf Leucovorin
Non-chemo IVP Lasix
Chemo infusion 5FU
Chemo infusion 5FU
0935 – 1245
1031
1101 – 1233
1250 – 1510
1250 – 1510
1540
1525 – 1539
(over 46 hours)
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96361 x1
1
96375
96413,, 96415
96417, 96415
96368
96376
96411
96416
53
Documentation - Review
What do I need to know?
–
–
–
–
Substance infused (chemo, non-chemo,
non chemo, hydration)
Route of administration (infusion, IV push, IM/SQ)
Access Site (RAC, LFA, etc.)
Time the service happened, including:
• Start time (infusion)
• Stop Time (infusion)
NO STOP TIME
TIME, NO INFUSION SERVICE
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Questions?
Jennifer Kennebeck, MBA, RHIA, CCS
Senior Client Partner, Operations
jkennebeck@g2n.org
Office: 314.835.9311
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