Billing and Coding: Infusion, Injection and Hydration Services

Palmetto GBA has received inquiries related to the billing and documentation of infusions, injections and hydration fluids. Documentation, medical necessity, and code assignment are very important. Infusion Therapy For purposes of facility coding, an infusion is required to be more than 15 minutes for safe and effective administration. Hydration therapy is always secondary to infusion/injection therapy. For example, if the initial administration infuses for 20 to 30 minutes the provider would bill one unit because the CPT ® (Cu rrent Procedural Terminology) /HCPCS (Healthcare Common Procedure Coding System) code states 'initial up to or first hour'. If an additional drug is administered and infused for 20 minutes no additional units would be billed, as the one hour increment has not been exceeded. The medication administration record and/or the nursing documentation should coincide with the billing based on time of initiation, time of completion, and discharge from the outpatient facility. Intravenous (IV) infusions are billed based upon the CPT ® /HCPCS description of the service rendered. A provider may bill for the total time of the infusion using the appropriate add-on codes (i.e. the CPT ® /HCPCS for each additional unit of time) if the times are documented. Providers may not bill separately for items/services that are part of the procedures (e.g., use of local anesthesia, IV start or preparation of chemotherapy agent). The appropriate CPT ® /HCPCS codes for the IV infusion/administration of drugs should be used with the appropriate number of units. Upon initiation of the infusion it is expected that the start time be documented as well as the stop time. The nursing documentation and/or medication administration record should indicate this information and be signed by the appropriate clinical staff. When requested, providers should submit documentation indicating the volume, start and stop times, and infusion rate (s) of any drugs and solution provided. In the absence of the stop time the provider should be able to calculate the infusion stop time with the volume, start time, and infusion rate. Injections/IV Push Therapy An intravenous injection (IV push) is an infusion of 15 minutes or less. If an IV push is administered the following criteria must be met: •A healthcare professional administering an injection is continuously present to administer and observe the patient •An infusion is administered lasting 15 minutes or less 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. Frequently Asked Questions In what order should hospitals bill infusion and injections? Consistent with the special instructions for facilities in the CPT ® manual, infusion should be primary, injections/IV pushes next and hydration therapy last. Infusion>Injection>Hydration). How many initial services may be billed per day? Only one initial code is allowed per patient encounter unless two separate IV sites are medically reasonable and necessary (use modifier 59). If the patient returns for a separate and medically reasonable and necessary visit/encounter on the same day, another initial code may be billed for that visit with CPT ® modifier 59. What is the difference between an IV push and an IV infusion? An IV push is an infusion of 15 minutes or less and requires that the health care professional administering the injection is continuously present to observe the patient. In order to bill an IV infusion, a delivery of more than 15 minutes is required for safe and effective administration. When can a sequential infusion be billed? Following the completion of the first infusion, sequential infusions may be billed for the administration of a different drug or service through the same IV access. There must be a clinical reason that justifies the sequential (rather than concurrent) infusion. Sequential infusions may also be billed only once per sequential infusion of same infusate mix. There is no concurrent code for either a chemotherapeutic IV infusion or hydration. Can a concurrent infusion be billed? Any hydration, therapeutic or chemotherapeutic infusion occurring at the same time and through the same IV access as another reportable initial or subsequent infusion is a concurrent infusion. Concurrent administration of hydration is not billable via a HCPCS code and not separately payable. In general, chemotherapeutics are not infused concurrently, however if a concurrent chemotherapy infusion were to occur, the infusion would be coded with the chemotherapeutic unlisted code. When can hydration be billed? Documentation must indicate that the hydration service is medically reasonable and necessary. It should not be an integral part of another service such as an operative procedure. The rate of infusion should be included in the documentation. When fluids are used solely to administer drugs or other substances, the process is considered incidental hydration and should not be billed. To code hydration as an initial service, hydration must be a medical necessity and administered for more than 30 minutes. Hydration of 30 minutes or less 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. Each additional hour of hydration infusion requires an initial service being delivered (hydration or other infusion/injection service). If a patient is receiving an IV infusion for hydration and the stop time is not documented in the medical record, how should the service be coded? Infusion times should be documented. Hydration of 30 minutes or less is not separately billable. When requested, providers should submit documentation indicating the volume, start and stop times, and infusion rate (s) of the solution provided. In the absence of the stop time the provider should be able to calculate the infusion stop time with the volume, start time, and infusion rate and code accordingly. What are the most frequent documentation problems in the area of infusion therapy? As with other Medicare contractor reviews, problems arise with insufficient or incomplete documentation. In the area of infusion therapy, several areas are affected. Problem areas are listed below. Intravenous Infusion Hydration Therapy •The physician order for hydration fluids administered during the encounter for drug administration, chemotherapy or blood administration is missing •No distinction is made between hydration administration that is the standard of care, facility protocol and/or drug protocol for administration of hydrating fluids, pre- or post-medications •Documentation is insufficient and does not support medical necessity of pre-hydration, simultaneous or subsequent hydration Infusion Services •Documentation does not confirm administration through a separate access site •Poor documentation for the line flush between drugs makes it impossible to determine whether compatible substances or drugs were administered concurrently or sequentially •The inadequate documentation of the access site and/or each drug's start and stop times makes it impossible to determine whether compatible substances or drugs were mixed in the same bag or syringe or administered separately •Start and/or stop times for each substance infused are often missing •The documentation of infusion services was started in the field by emergency medical services (EMS) and continued in the emergency department (ED) •Documentation of infusion services that were initiated in the ED continued upon admission to outpatient observation status •Working with vendors on electronic health records (EHR) to implement revisions to electronic forms in order to comply with changing documentation requirements was difficult Recommended Documentation Plan •Develop and/or revise documentation forms that conform to the coding guidelines for injections, IV pushes, and IV infusions •Clinical personnel should focus on patient care and ensure accurate and complete documentation of the encounter •The pharmacist should communicate the classification of the drug, fluid or substance to aide in the correct application of procedure codes In addition to the above, health information management (HIM) coding professionals should ensure accurate coding through review of documentation in the patient record to: •Apply official coding guidelines •Assign CPT ® /HCPCS infusion codes •Apply modifiers (if indicated) •Generate charges for infusion-administration services •Review accuracy of drug codes and associated billing units

Upon initiation of the infusion it is expected that the start time be documented as well as the stop time. The nursing documentation and/or medication administration record should indicate this information and be signed by the appropriate clinical staff. When requested, providers should submit documentation indicating the volume, start and stop times, and infusion rate (s) of any drugs and solution provided. In the absence of the stop time the provider should be able to calculate the infusion stop time with the volume, start time, and infusion rate. The medication administration record and/or the nursing documentation should coincide with the billing based on time of initiation, time of completion, and discharge from the outpatient facility. Documentation must indicate that the hydration service is medically reasonable and necessary. The rate of infusion should be included in the documentation.