Hydration,IVInfusions,InjectionsandVaccineChargeProcess
There are a number of items to be considered when billing for the Nursing service to perform drug therapy, the charge process is divided into three specific groups of codes and processes. 1.
2.
3.
Hydration and IV Therapy Injections into IV lines and intramuscular Vaccines Hydration and IV Therapy: Hydration and IV therapy are time based charges, which have a first hour and a subsequent hour. The codes are as follows: 96360 ‐ Intravenous infusion, hydration; initial, 31 minutes to 1 hour
96361 ‐ Intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure), the additional time has to be greater than 30 minutes 96365 ‐ Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour, 16‐60 minutes (less than 16 min = IVP) 96366 ‐ Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure) 96367 ‐ Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion, up to 1 hour (List separately in addition to code for primary procedure), 16‐60 minutes and a different drug 96368 ‐ Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure), once per encounter 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), 16‐60 minutes 96370 ‐ Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure), must be greater than 30 minutes 96371 ‐ Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); additional pump set‐up with establishment of new subcutaneous infusion site(s) (List separately in addition to code for primary procedure), once per encounter Hydration therapy must last longer than 30 minutes, to be considered for an initial 1st hour code. IV therapy less than 16 minutes is to be coded as an IV injection. Hydration less than 30 minutes is not a billable procedure. Establishing a heparin or saline lock for access or a slow drip of saline for access is not hydration or IV therapy. PARAHealthcareFinancialServices–March2012
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Injections into IV lines are required to be classed into the following codes: 1.
2.
3.
Initial injection med A (96374) Additional subsequent injection, meds B – Z (96375) Additional subsequent injections med A (96376), there must be a period of more than 30 minutes that has to pass between injections of same drug. The codes used for IV injections are as follows: 96374 ‐ Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug 96375 ‐ Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure) 96376 ‐ Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility (List separately in addition to code for primary procedure) see time note above Intramuscular, subcutaneous and intra‐arterial injections use the following codes: 96372 ‐ Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular 96373 ‐ Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intra‐arterial Vaccines are based on the number of injections and for Medicare the type of vaccine: 90471 ‐ Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid) 90472 ‐ Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) G0008 / G9141 ‐ ADMINISTRATION OF INFLUENZA VIRUS / H1N1 VACCINE
G0009 ‐ ADMINISTRATION OF PNEUMOCOCCAL VACCINE
G0010 ‐ ADMINISTRATION OF HEPATITIS B VACCINE – not billable hospital outpatient Part B PARAHealthcareFinancialServices–March2012
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General rules: There can only be one “initial” procedure, on a claim / encounter. The ranking to determine the initial procedure is as follows, the remaining procedures must be coded as additional or subsequent. 1.
2.
3.
4.
5.
Chemotherapy services 96365 – IV therapy 1st hour 96374 – IV injection initial Any other infusion/IV therapy code precedes a hydration code 96360 – Hydration 1st hour‐this code used as “initial” only if NO OTHER drug is administered as an infusion or IV therapy Establishing IV access is not hydration or IV therapy. Hydration procedures must have a diagnosis supporting the procedure, hydration substances include normal saline, D5W, and pre‐packaged KCL. Initial IV therapy must last longer than 15minutes, but if less than 16 minutes, the procedure should be charged as an IV injection. Drug admin charges are only reported on outpatient/ambulatory care, emergency and observation patients, the service is not charged on inpatients. There are a number of different revenue codes which can be used to report these services; the basic guideline is to list the charge against the “nursing station” providing the service. For the charge for an “additional” hour of hydration or IV med therapy the service must last for more than 30 minutes into the additional hour. 0260 ‐ IV Therapy ‐ General Classification 0450 ‐ Emergency Room ‐ General Classification
0456 ‐ Emergency Room ‐ Urgent Care 0510 ‐ Clinic ‐ General Classification 0516 ‐ Clinic ‐ Urgent Care Clinic 0761 ‐ Treatment or Observation Room ‐ Treatment Room
0762 ‐ Treatment or Observation Room ‐ Observation Room
0940 ‐ Other Therapeutic Services ‐ General Classification
PARAHealthcareFinancialServices–March2012
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General rules (continued): “If performed to facilitate the infusion or injection, the following services are included and are not reported separately” ‐ referenced in AMA CPT Nomenclature: 1.
2.
3.
4.
5.
Use of local anesthesia IV start Access to indwelling IV, subcutaneous catheter or port Flush at conclusion of infusion Standard tubing, syringes, and supplies For Declotting of a catheter or port, use 36593 The definition of when a “chemo” code is to be billed instead of an IV med therapy is a function of the requirements of the drug preparation and the Nurse performing the procedure. A quote from AMA CPT: “See codes 96401 – 96549 for the administration of chemotherapy or other highly complex drug or highly complex biologic agent services. These highly complex services require advanced practice training and competency for Staff who provide these services; special consideration for the preparation, dosage or disposal; and commonly, these services entail significant patient risk and frequent monitoring. Examples are frequent changes in the infusion rate, prolonged presence of nurse administering the solution for patient monitoring and infusion adjustments, and frequent conferring with the physician about these issues.” PARAHealthcareFinancialServices–March2012
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Vaccines: The codes associated with vaccine administration are as follows: These codes are for the Nursing service, the drug costs are to be attached to the product codes 90476 – 90749, sample pasted below. PARAHealthcareFinancialServices–March2012
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Complex drugs and biologic agents are to be billed using the chemotherapy codes: 96401 ‐ Chemotherapy administration, subcutaneous or intramuscular; non‐hormonal anti‐neoplastic 96402 ‐ Chemotherapy administration, subcutaneous or intramuscular; hormonal anti‐neoplastic 96405 ‐ Chemotherapy administration; intralesional, up to and including 7 lesions 96406 ‐ Chemotherapy administration; intralesional, more than 7 lesions 96409 ‐ Chemotherapy administration; intravenous, push technique, single or initial substance/drug 96411 ‐ Chemotherapy administration; intravenous, push technique, each additional substance/drug (List separately in addition to code for primary procedure) 96413 ‐ Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug 96415 ‐ Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure) 96416 ‐ Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump 96417 ‐ Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to 1 hour (List separately in addition to code for primary procedure) 96420 ‐ Chemotherapy administration, intra‐arterial; push technique 96422 ‐ Chemotherapy administration, intra‐arterial; infusion technique, up to 1 hour 96423 ‐ Chemotherapy administration, intra‐arterial; infusion technique, each additional hour (List separately in addition to code for primary procedure) 96425 ‐ Chemotherapy administration, intra‐arterial; infusion technique, initiation of prolonged infusion (more than 8 hours), requiring the use of a portable or implantable pump 96440 ‐ Chemotherapy administration into pleural cavity, requiring and including thoracentesis 96446 ‐ Chemotherapy administration into peritoneal cavity via indwelling port or catheter 96450 ‐ Chemotherapy administration, into CNS (eg, intrathecal), requiring and including spinal puncture PARAHealthcareFinancialServices–March2012
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Drugs and Biologicals related to Chemotherapy Table A. Limited coverage is being established by CMS for these drugs on List A C9257 ‐ INJECTION, BEVACIZUMAB, 0.25 MG J0894 ‐ INJECTION, DECITABINE, 1 MG J9001 ‐ INJECTION, DOXORUBICIN HYDROCHLORIDE, ALL LIPID FORMULATIONS, 10 MG J9010 ‐ INJECTION, ALEMTUZUMAB, 10 MG J9015 ‐ INJECTION, ALDESLEUKIN, PER SINGLE USE VIAL J9017 ‐ INJECTION, ARSENIC TRIOXIDE, 1 MG J9025 ‐ INJECTION, AZACITIDINE, 1 MG J9033 ‐ INJECTION, BENDAMUSTINE HCL, 1 MG J9035 ‐ INJECTION, BEVACIZUMAB, 10 MG J9041 ‐ INJECTION, BORTEZOMIB, 0.1 MG J9043 ‐ INJECTION, CABAZITAXEL, 1 MG J9171 ‐ INJECTION, DOCETAXEL, 1 MG J9179 ‐ INJECTION, ERIBULIN MESYLATE, 0.1 MG J9201 ‐ INJECTION, GEMCITABINE HYDROCHLORIDE, 200 MG J9206 ‐ INJECTION, IRINOTECAN, 20 MG J9207 ‐ INJECTION, IXABEPILONE, 1 MG J9214 ‐ INJECTION, INTERFERON, ALFA‐2B, RECOMBINANT, 1 MILLION UNITS J9228 ‐ INJECTION, IPILIMUMAB, 1 MG J9263 ‐ INJECTION, OXALIPLATIN, 0.5 MG J9264 ‐ INJECTION, PACLITAXEL PROTEIN‐BOUND PARTICLES, 1 MG J9265 ‐ INJECTION, PACLITAXEL, 30 MG J9302 ‐ INJECTION, OFATUMUMAB, 10 MG J9305 ‐ INJECTION, PEMETREXED, 10 MG J9310 ‐ INJECTION, RITUXIMAB, 100 MG J9330 ‐ INJECTION, TEMSIROLIMUS, 1 MG J9351 ‐ INJECTION, TOPOTECAN, 0.1 MG J9395 ‐ INJECTION, FULVESTRANT, 25 MG J9999 ‐ NOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC DRUGS PARAHealthcareFinancialServices–March2012
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Drugs and Biologicals related to Chemotherapy (continued)
Table B. The FI/Contractor expects the use of these drugs on List B will be reasonable and necessary
J9000 ‐ INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG J9020 ‐ INJECTION, ASPARAGINASE, 10,000 UNITS J9027 ‐ INJECTION, CLOFARABINE, 1 MG J9031 ‐ BCG (INTRAVESICAL) PER INSTILLATION J9040 ‐ INJECTION, BLEOMYCIN SULFATE, 15 UNITS J9045 ‐ INJECTION, CARBOPLATIN, 50 MG J9050 ‐ INJECTION, CARMUSTINE, 100 MG J9055 ‐ INJECTION, CETUXIMAB, 10 MG J9060 ‐ INJECTION, CISPLATIN, POWDER OR SOLUTION, 10 MG J9065 ‐ INJECTION, CLADRIBINE, PER 1 MG J9070 ‐ CYCLOPHOSPHAMIDE, 100 MG J9098 ‐ INJECTION, CYTARABINE LIPOSOME, 10 MG J9100 ‐ INJECTION, CYTARABINE, 100 MG J9120 ‐ INJECTION, DACTINOMYCIN, 0.5 MG J9130 ‐ DACARBAZINE, 100 MG J9150 ‐ INJECTION, DAUNORUBICIN, 10 MG J9151 ‐ INJECTION, DAUNORUBICIN CITRATE, LIPOSOMAL FORMULATION, 10 MG J9160 ‐ INJECTION, DENILEUKIN DIFTITOX, 300 MICROGRAMS PARAHealthcareFinancialServices–March2012
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Drugs and Biologicals related to Chemotherapy (Table B continued) J9165 ‐ INJECTION, DIETHYLSTILBESTROL DIPHOSPHATE, 250 MG J9178 ‐ INJECTION, EPIRUBICIN HCL, 2 MG J9181 ‐ INJECTION, ETOPOSIDE, 10 MG J9185 ‐ INJECTION, FLUDARABINE PHOSPHATE, 50 MG J9190 ‐ INJECTION, FLUOROURACIL, 500 MG J9200 ‐ INJECTION, FLOXURIDINE, 500 MG J9208 ‐ INJECTION, IFOSFAMIDE, 1 GRAM J9209 ‐ INJECTION, MESNA, 200 MG J9211 ‐ INJECTION, IDARUBICIN HYDROCHLORIDE, 5 MG J9215 ‐ INJECTION, INTERFERON, ALFA‐N3, (HUMAN LEUKOCYTE DERIVED), 250,000 IU J9230 ‐ INJECTION, MECHLORETHAMINE HYDROCHLORIDE, (NITROGEN MUSTARD), 10 MG J9245 ‐ INJECTION, MELPHALAN HYDROCHLORIDE, 50 MG J9250 ‐ METHOTREXATE SODIUM, 5 MG J9260 ‐ METHOTREXATE SODIUM, 50 MG J9261 ‐ INJECTION, NELARABINE, 50 MG J9266 ‐ INJECTION, PEGASPARGASE, PER SINGLE DOSE VIAL J9268 ‐ INJECTION, PENTOSTATIN, 10 MG J9270 ‐ INJECTION, PLICAMYCIN, 2.5 MG PARAHealthcareFinancialServices–March2012
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Drugs and Biologicals related to Chemotherapy (Table B continued) J9280 ‐ MITOMYCIN, 5 MG J9293 ‐ INJECTION, MITOXANTRONE HYDROCHLORIDE, PER 5 MG J9300 ‐ INJECTION, GEMTUZUMAB OZOGAMICIN, 5 MG J9303 ‐ INJECTION, PANITUMUMAB, 10 MG J9320 ‐ INJECTION, STREPTOZOCIN, 1 GRAM J9340 ‐ INJECTION, THIOTEPA, 15 MG J9357 ‐ INJECTION, VALRUBICIN, INTRAVESICAL, 200 MG J9360 ‐ INJECTION, VINBLASTINE SULFATE, 1 MG J9370 ‐ VINCRISTINE SULFATE, 1 MG J9390 ‐ INJECTION, VINORELBINE TARTRATE, 10 MG J9600 ‐ INJECTION, PORFIMER SODIUM, 75 MG PARAHealthcareFinancialServices–March2012
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Drugs and Biologicals outside the 9000 range Table C. These drugs can be billed with Chemo Administration codes J0128 ‐ INJECTION, ABARELIX, 10 MG J0215 ‐ INJECTION, ALEFACEPT, 0.5 MG J0970 ‐ INJECTION, ESTRADIOL VALERATE, UP TO 40 MG J1000 ‐ INJECTION, DEPO‐ESTRADIOL CYPIONATE, UP TO 5 MG J1380 ‐ INJECTION, ESTRADIOL VALERATE, UP TO 10 MG J1390 ‐ INJECTION, ESTRADIOL VALERATE, UP TO 20 MG J1410 ‐ INJECTION, ESTROGEN CONJUGATED, PER 25 MG J1435 ‐ INJECTION, ESTRONE, PER 1 MG J3315 ‐ INJECTION, TRIPTORELIN PAMOATE, 3.75 MG J7516 ‐ CYCLOSPORIN, PARENTERAL, 250 MG J7525 ‐ TACROLIMUS, PARENTERAL, 5 MG J9355 ‐ INJECTION, TRASTUZUMAB, 10 MG Q3025 ‐ INJECTION, INTERFERON BETA‐1A, 11 MCG FOR INTRAMUSCULAR USE PARAHealthcareFinancialServices–March2012
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Billing Examples Service Patient receives a saline/hep lock for access 1. 2. Patient receives infusion TKO at a rate of 100 ml/hr for a period of 2 hours Infusion of a fluid for access TKO/KVO is not a billable event Hydration must last longer than 30 minutes to be billable None Med infusions less than 16 minutes are to be billed as a IVP injection 96374 Patient receives hydration of 89 minutes 5. Patient receives hydration for 45 minutes and a med 6. injection into the IV line, there is not a medical condition to require the hydration Patient receives hydration for 45 minutes and a med injection 7. into the IV line, there is a medical condition to require the hydration Patient receives IV infusion for 91 minutes, on the 45th minute 8. the Patient receives a 2nd med same site / line infusion for 45 minutes Billing Code Description Insertion of an access site catheter does not create a billable event None Patient receives a med infusion of less than 16 minutes 4. None Patient receives a hydration infusion "bolus" of less than 30 minutes 3. Billing Codes 96360 Patient is to be billed for 1 hour hydration, additional hours require greater than 30 minutes of additional time If the hydration is only a method to admin the drug through the IV line the Patient should only be billed for the IV injection, but not the infusion 96374 If there is a medical requirement for the hydration, then both codes are billable, bill only one initial per encounter, IVP outranks hydration 96361 96374 Patient is to be billed for 1st hour med infusion, additional hour infusion (greater than 30 minutes), and 1 hour concurrent med infusion 96365 96366 96368 PARAHealthcareFinancialServices–March2012
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9. 10. 11. 12. 13. 14. Patient receives IV infusion for 90 minutes, on the 91st minute the Patient receives a 2nd med same site for 45 minutes Patient receives IV infusion for 91 minutes, the Patient then receives a 2nd med, new site and pump for 45 minutes Patient receives med infusion for 45 minutes, and a 2nd drug is injected into the IV line Patient receives med infusion for 45 minutes, and a 2nd drug is injection into the IV line, and then 31 minutes later the same drug is injected into the IV line Patient receives med infusion for 45 minutes, and a 2nd drug is injection into the IV line, and then 20 minutes later the same drug is injected into the IV line Patient receives med infusion for 45 minutes, and a 2nd drug is injected into the IV line, and then a 3rd drug is injected into the IV line Patient is to be billed for 1st hour med infusion, add hour infusion, and 1 hour sequential med infusion new site Patient is to be billed for a IV med infusion, plus a IV injection, only one initial code per encounter 96365 96375 Patient is to be billed for IV med infusion, injection of a drug into IV line, and then the same drug injected into a IV line, outside the 30 minute inclusion limit 96365 96375 96376 Patient is to be billed for IV med infusion, injection of a drug into IV line, because the same drug was injected within 30 minutes no additional code(s) 96365 96375 96365 96375 x 2 Patient is to be billed for a IV med infusion, injection into a IV line, and sequential drug injection into a IV line 96372 90471 Patient is injected the same drug twice IM 15 minutes apart 16. 96365 96366 96367 Patient is injected a pain med IM and then also a vaccine 15. Patient is to be billed for 1st hour med infusion, and 1 hour sequential med infusion, 2nd hour infusion requires greater than 30 minutes 96365 96367 Patient is to be billed im injection and a vaccine admin injection 96372 x 2 Patient is to be billed the im injection twice PARAHealthcareFinancialServices–March2012
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