Over the next several months, “Spotlight on CPT”, will be sharing information on Infusion and Injection coding. This is an area that continually causes confusion amongst many coding professionals. Let’s start with the basics this month.
First, I should clarify that this information is for facility coding of infusions and injections not physician/provider coding. The codes that should be used are found in the CPT Manual in the Medicine Section under Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions, and Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration. It is important to point out that within this section there are a number of notes provided to help coding professionals understand what is meant by some of the terms used, such as “sequential” or “concurrent” infusions, and how to properly assign these codes.
There is a hierarchy to the “initial” code assignment as
follows:
Chemotherapy Services
Therapeutic, Prophylactic, and Diagnostic Services
Hydration Services
Coding professionals must also recognize that a hierarchy exists when coding for the method of administration for these services as follows:
Infusions
Pushes
Injections
Within the notes for this section of codes, intravenous or intra-arterial pushes are defined as follows:
Included in these procedures are:
Starting the IV
Accessing an existing IV, subcutaneous catheter, or port
Flushing
Using tubes, syringes, and supplies
Documentation related to infusion and injections is notoriously challenging. Here are some documentation areas to be aware of.
Mode of administration (IVP, IVPB, IV, IM, SC, SQ)
Access site
Start and stop time
Rate of administration
Dose/volume administered
Time of interruptions/infiltrations
Flushes or clearing of line that take place
As most coding professionals who code for infusions can testify, one of the hardest documentation areas to capture is the start and stop time of the infusion. However, it is actually one of the most vital components required to assign the correct CPT code. The time is calculated based on the total run time of the infusion. This does not include initiation of the IV access, or when it is discontinued. Nor should the patient’s discharge time be used as the infusion’s stop time. Pre- or post-procedure time spent monitoring the patient is also not included in the run time. Additionally, when taking time into consideration, it can only be counted once and this will factor into coding concurrent or sequential infusions.
Next month, “Spotlight on CPT” will explore coding for hydration services.
Now, light has been shed on coding infusions and injections.
About the Author
Dianna Foley, RHIA, CHPS, CCS, CDIP, is an HIM professional with over 25 years of experience. She earned her bachelor’s degree from the University of Cincinnati and holds RHIA, CHPS, CDIP, and CCS certifications from AHIMA, along with being an AHIMA-approved ICD-10-CM/PCS trainer. Dianna has held many positions in HIM and is now an independent coding consultant. She previously served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna is an AHIMA-published author and has volunteered with AHIMA on projects including certification item writing, certification exam development, coding rapid design, and most recently has served on AHIMA’s nominating committee. She is a presenter on coding topics at the national, state, and regional levels and serves as OHIMA’s Education Coordinator. Dianna mentors new AHIMA members and also provides monthly educational lectures to coders and clinical documentation specialists.
