Clarifying the Infusion and Injection Quandary
Coding infusions and injections has been a source of confusion and frustration since the Centers for Medicare and Medicaid Services (CMS) introduced C codes in 2006. However, in calendar year 2007, CMS made an about face and eliminated the C codes, reverting back to the published 2007 CPT codes. The only exception to this rule is code C8957, Nonchemo prolonged infusion pump.
Coders must understand these guidelines in order to code these services correctly so that their organizations are reimbursed fully. This article outlines the basic application of these CPT/HCPCS codes from a hospital outpatient service and CMS perspective. (Note: payers differ on code requirements and coverage for infusions and injections.
This list assigns the highest priority to chemotherapy infusions; however, it is important for coders to know the primary reason that a patient seeks services. Clinical documentation is an important part of appropriate injection and infusion coding and billing.
Injection versus Infusion
Length of time, calculated by the start and stop times, determines whether a procedure is coded as an infusion or injection. To ensure accurate coding and billing, providers must understand the start and stop documentation requirement. Any infusion less than 15 minutes should be coded as an intravenous push injection.
This year, CMS adjusted six new APC levels, which allows for a separate payment for the initial administration and additional payments for each additional hour of infusion.
Injections are included in CPT codes 90772–90779, 96401–96411, and 96440–96450. There are several types of injections, including intravenous push, intramuscular, subcutaneous, and intra-arterial.
An injection lasts 15 minutes or less and may be therapeutic, chemotherapeutic, or for immunization. Clinical documentation should include the injection type, purpose, and duration.
Chemotherapeutic injections include hormonal, nonhormonal, intralesional, intravenous push, intra-arterial push, pleural cavity, peritoneal cavity, and intrathecal. Immune globulin administration is coded using injection codes.
It is important to remember that injections are coded per injection, not per medication.
Vaccine administration is immunization as a preventive measure against specific conditions. A vaccine administration code should be assigned whenever a vaccine product is used.
CMS has assigned reimbursement for vaccine administration beginning in calendar year 2007 under the outpatient prospective payment system (OPPS). Vaccine administration is coded with CPT codes (90465–90474) or HCPCS codes (G0008, G0009, G0377). This service is a frequently missed charge in emergency departments.
Hydration and nonchemotherapeutic and chemotherapeutic services are included in infusion codes. Chemotherapeutic infusions may include antineoplastic agents for treatment of noncancer diagnoses, substances such as monoclonal antibody agents, and other biologic response modifiers. Coders should identify the primary reason for the visit before assigning the infusion code.
CMS began reimbursing infusions on a per-hour basis beginning in calendar year 2007 under OPPS. The following guidelines apply when coding for infusions:
- Only one initial service may be coded per encounter.
- A bolus of prepackaged fluids or other specific medications should be coded as therapeutic.
- The calculation of hours is based on start and stop times. The additional hour can be included only when the infusion has lasted more than 30 minutes into the second hour.
- Concurrent chemotherapy should be assigned code 96549.
- Concurrent nonchemotherapy infusion should be assigned code 90768 with a unit of one per encounter.
- Prolonged infusions requiring a pump are coded to C8957 for Medicare patients. Other payers may need to be queried for an appropriate crosswalk.
According to the 2007 CPT codebook, anesthesia; IV start; access to indwelling IV, subcutaneous catheter, or port, catheter flush at conclusion of infusion; and standard tubing, syringes, and supplies are included in the CPT code. There are services that may be charged separately. They include:
- 96521, Refilling and maintenance of portable pump
- 96522, Refilling and maintenance of implantable pump or reservoir for delivery, system (e.g., intravenous, intra-arterial)
- 96523, Irrigation of implanted venous access device for drug delivery systems
- 99201–99205; 99211–99215, Separate clinic visits for complications of care or separately identifiable problem during patient’s clinic visit
- G0332, Pre-administration services for the administration of intravenous immune globulin
Billing infusion and injection services requires coordination between the chargemaster coordinator, coders, and billing staff. Organizations should consider the following questions:
- How will these services be charged?
- Will codes be assigned by coders or the chargemaster?
- Who will provide the education on the charging process and requirements?
- Who will review OCE results?
- How will the OCE results be resolved?
These services create billing issues and are an area of frequently missed charges. In some facilities the assignment of injection and infusion codes has been moved from the clinic (nursing staff) to the HIM coding department. Coders have the ability to review the documentation within the record and apply the appropriate CPT code that reflects the services provided.
Other facilities have chosen to assign a team of individuals to review issues such as this in a weekly or monthly meeting. The team consists of coders, billers, nurses, chargemaster personnel, and possibly emergency department personnel. The team can meet and review issues surrounding their facility’s issues with appropriate injection and infusion coding. In addition, these meetings can result in the development of educational materials for clinical providers to ensure that clinical documentation supports the services rendered and accurately reflects the patient’s care.