Continuing with the discussion of infusion and injection coding, this episode of “Spotlight on CPT” covers therapeutic, prophylactic, and diagnostic injections and infusions. Recall in our last installment, we covered the CPT coding related to hydration services. The CPT coding for therapeutic, prophylactic, or diagnostic injections and infusions is different in that they are used for the administration of drugs or substances. Fluid that is used to facilitate the administration of the drug should be considered incidental hydration and not separately reported.
Many of the codes that fall in the therapeutic, prophylactic, and diagnostic injection and infusion range (96365-96379) are time based. The first of these is 96365 for an initial IV infusion up to 1 hour. Add-on code 96366 is used for each additional hour. Just like the add-on hydration reporting, 96366 can only be assigned when more than 30 minutes of treatment is provided past the initial hour. Again, that means that in order to assign 96366, more than 90 minutes of infusion time must take place.
It must be noted that only one “initial” service code can be assigned with the assignment based on the hierarchy discussed in Part 1 of this series. However, if the patient’s condition or protocol requires that two distinct IV sites are used, then an additional “initial” service may be coded. Coding professionals should append modifier 59 to the second “initial” code. This will capture the additional time and effort for establishing this extra IV access. Restarting of an IV, using an additional IV to achieve the desired flow rate, or using port of a multi-lumen catheter are not reasons to code for an additional “initial” service.
Another add-on code to the initial infusion is 96367 for an additional sequential infusion. Again, this is for up to 1 hour of infusion time and must be for infusion of a new drug or substance after an initial service. This code may be assigned only once per sequential infusion of the same infusate mix.
Concurrent infusion treatment is assigned to add-on code 96368. When an infusion is running concurrently, it means it is running at the same time as the infusion of another different substance or drug. 96368 may only be assigned once per day regardless of how many new medications or substances are administered concurrently. This code is not time based.
There are two “initial” IV push codes, 96373 (intra-arterial) and 96374 (intravenous). Remember that in CPT, an IV push is defined as an infusion of 15 minutes or less or an injection requiring monitoring of the patient continuously during the administration. It should be noted that a CMS billing and coding article on infusion, injection, and hydration services (A53778) indicates that both components of the CPT definition must be met to assign a push.
There are also two “sequential” IV push add-on codes. 96375 would be used for a sequential push of a new drug, where 96376 would be assigned for a sequential push of the same drug. Sequential pushes of the same drug can only be assigned when more than 30 minutes has passed since the last push.
One final point to consider regarding IV pushes: a CPT Assistant from 2009 states that if the administration time for an IV push exceeds 15 minutes, the code for the service performed should be assigned, meaning to assign an infusion code.
Now, light has been shed on coding therapeutic, prophylactic, and diagnostic injections and infusions.
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.
