# Injections and infusions



## LTibbetts (Mar 12, 2010)

We are having yet another injection debate in the office and I was hoping to get feedback on this. I code for a small rural ER and I code the pro fees. The facility fees are done by a unit secretary in the ER and they do it by CDM, not CPT. No one up there is a coder and they don't even see CPT codes so we are having to clean up their messes constantly and hopefully, we are finally going to be able to do it ourselves soon. 

The biggest problem is the hydration issue. They are constantly putting two _initial _codes on there, one for initial hydration and one for initial drug pushes. Now I realize that you are only allowed one initial per chart and we have told them that. But what about patients that come in with gastroenteritis or dehydration and get hydrated and then recieve drugs via IVP. Now, according to the heirarchy, as soon as they receive drugs, the hydration becomes incidental. Isn't that correct? But is that the case even when the patient comes in for dehydration? The patient also got Zofran, and fentanyl, which again, is related to the reason the patient is here in the first place...belly pain, N&V, dehydration, etc.

My supervisor wants to charge for both the infusion and the drug and have us put a -59 modifier on it because she says it's two different things. You just can't get around the _initial _code rule so I don't know how it could work. I don't agree and furthermore, I am hesitant to mess with that -59 code. I know how abused and overused it is. Can anyone help me with this?


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## alicm (Mar 12, 2010)

you are absolutely correct in your knowledge of the heirarchy of the infusions. The only way to charge 2 initial's is if there are 2 distinct sites for infusion...therefore if the patient is having an infusion in both arms (example) then you can charge for both initials...
It was explained to me like this: 
an IVPB is the KING and he is always in charge no matter when he enters the room (the initial charge)
the IVP is the QUEEN and she is second and can only be the in-charge (initial) if the KING is not around (if a piggy-back was never administered)
the hydration is the PRINCE and he can only be in-charge (initial) if the KING and QUEEN are not around...and have never entered the room ...
sounds a little silly, but it really helped me keep the heirarchy in order...

if there are 2 kingdoms (two seperate identifable areas of infusions) then and only then can you have another KING/QUEEN/PRINCE

good luck explaining that to your supervisor without her thinking you are a little bizarre!!


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## eadun2000 (Mar 12, 2010)

LTibbetts said:


> We are having yet another injection debate in the office and I was hoping to get feedback on this. I code for a small rural ER and I code the pro fees. The facility fees are done by a unit secretary in the ER and they do it by CDM, not CPT. No one up there is a coder and they don't even see CPT codes so we are having to clean up their messes constantly and hopefully, we are finally going to be able to do it ourselves soon.
> 
> The biggest problem is the hydration issue. They are constantly putting two _initial _codes on there, one for initial hydration and one for initial drug pushes. Now I realize that you are only allowed one initial per chart and we have told them that. But what about patients that come in with gastroenteritis or dehydration and get hydrated and then recieve drugs via IVP. Now, according to the heirarchy, as soon as they receive drugs, the hydration becomes incidental. Isn't that correct? But is that the case even when the patient comes in for dehydration? The patient also got Zofran, and fentanyl, which again, is related to the reason the patient is here in the first place...belly pain, N&V, dehydration, etc.
> 
> My supervisor wants to charge for both the infusion and the drug and have us put a -59 modifier on it because she says it's two different things. You just can't get around the _initial _code rule so I don't know how it could work. I don't agree and furthermore, I am hesitant to mess with that -59 code. I know how abused and overused it is. Can anyone help me with this?



You can code injections with hydrations.  The primary code would be 96374.  For the hydration, you would code it as secondary with a 96361.  Just remember that infusions come first, followed by injections followed by hydration.  For example, you had an infusion of Avelox for 32 minutes, an IVP of Toradol and Phenergan and an hour of hydration.  It would be 96365; 96375 x2 and 96361.


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## LTibbetts (Mar 15, 2010)

eaudun2000, thank you but I thought you should know that the 96361 is an add-on code and can only be used when the primary procedure code, 96360, has been used, it can not be used as a  "subsequent code" without a parent code, but thank you for your response anyway.

Alicm, thank you so much!! I thought that story was pretty funny, actually, and I can't tell you how much easier that will be for me to remember. It's funny the things that stick with you, isn't it? Just one more thing, though, if you don't mind. What about the case of the patient here for only hydration and ends up getting zofran for the nausea, is it the same _royal_ explanation? And also, do you know if there is anything about this specific topic on the CMS website and where to find it? I've searched but am not having much luck. Thanks again


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## mitchellde (Mar 15, 2010)

eadun2000 said:


> You can code injections with hydrations.  The primary code would be 96374.  For the hydration, you would code it as secondary with a 96361.  Just remember that infusions come first, followed by injections followed by hydration.  For example, you had an infusion of Avelox for 32 minutes, an IVP of Toradol and Phenergan and an hour of hydration.  It would be 96365; 96375 x2 and 96361.



Leslie is correct, you must code the initial as the initial reason the patient received the fluids, in this case the hydration is the initial and the push is subsequent.  I liked the king, queen . prince story though that is priceless!


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## eadun2000 (Mar 15, 2010)

LTibbetts said:


> eaudun2000, thank you but I thought you should know that the 96361 is an add-on code and can only be used when the primary procedure code, 96360, has been used, it can not be used as a  "subsequent code" without a parent code, but thank you for your response anyway.
> 
> Alicm, thank you so much!! I thought that story was pretty funny, actually, and I can't tell you how much easier that will be for me to remember. It's funny the things that stick with you, isn't it? Just one more thing, though, if you don't mind. What about the case of the patient here for only hydration and ends up getting zofran for the nausea, is it the same _royal_ explanation? And also, do you know if there is anything about this specific topic on the CMS website and where to find it? I've searched but am not having much luck. Thanks again



LTibbetts,

Just as an FYI, yes 96361 is an add on code, but is to be used with a primary.. primary is either 96365 (infusion) 96374 (injection) or 96360 (hydration).  It did not make sense to me for the longest time of why you have to use 96361 without the 96360, but if you look in the CPT book it explains that 96361 is an add on code for above three codes.  I do know that infusions are listed first, followed by injections, followed by hydrations.


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## LTibbetts (Mar 15, 2010)

eadun200, you're right I just got off the phone with a coding consulting firm that we sometimes work with and that is exactly what they explained to me. The injections are going to be the death of me...aarrgghhh!

Deb, doesn't the heirarchy state that the IV push trumps the hydration? Even if the pt comes in for dehydration? This is where I get confused. I can't find anything in writing anywhere to back this up and my supervisor is saying that it trumps no matter what. Now she is telling me that we can charge the 96361 even if they don't have hydration is for under 31 minutes. That one, I completely disagree with. Am I wrong again?  Help...


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## mitchellde (Mar 15, 2010)

I believe that on the AMA web they state that you use the initial service as the reason for the infusion so the hydration is the intial code.  The hirearchy is for facility billing and not the physician.  Also you are correct if the hydration is less than 30 minutes thenit is not billable and the reson is that if it is less than that then it is not therapeutic and cannot be dehydration.  I will check on what I have but I know this is stated somewhere.


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## mitchellde (Mar 15, 2010)

Leslie in the CPT book it states:
"When reported by the physician, report the 'initial' code that best describes the primary reason for the encounter regardless of the order in which the infusions or injections are administered.
When reported by the facility the 'initial' code should be reported in the order of chemotherapy services followed by therapeutic/prophylactic/diagnostic services, followed by hydration services, followed by infusions, followed by pushes, and finally injections."
Therefor if the reason for the infusion was for hydration then that is your initial code, but if it does not run for at least 31 minutes then per the rules you may not report the infusion.


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## LTibbetts (Mar 15, 2010)

Thank you so much, Deb!! I just brought this post into my supervisors office and showed her. If you do happen to come across anything in writing anywhere, can you please send the link to me? She is still being a little sketchy about it. She is still thinking that we can charge that subsequent hydration code if under 31 minutes, since we miss out on the intitial hydration code because of the IV push. I told her it was fraud and that I would refuse to do it and she could if she chose to but I don't want anything to do with it. I told her that timed codes are just that.._timed_ codes...but she is taking advice from someone else now. 

We are taking over the facility coding for injections and infusions so we will be doing a lot of these in the very near future so I appreciate your fast responses.  

Remember to let me know when you come to Bar Harbor so I can buy you lunch or dinner


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## eadun2000 (Mar 15, 2010)

LTibbetts said:


> eadun200, you're right I just got off the phone with a coding consulting firm that we sometimes work with and that is exactly what they explained to me. The injections are going to be the death of me...aarrgghhh!
> 
> Deb, doesn't the heirarchy state that the IV push trumps the hydration? Even if the pt comes in for dehydration? This is where I get confused. I can't find anything in writing anywhere to back this up and my supervisor is saying that it trumps no matter what. Now she is telling me that we can charge the 96361 even if they don't have hydration is for under 31 minutes. That one, I completely disagree with. Am I wrong again?  Help...



You are 1000% right!  Say, for instance, a patient comes in with dehydration but fell and hurt his hip (I know stretching it, but just bear with me).  They started hydration for the dehydration and gave a dilaudid push.  It would be coded 96374 and 96361 (granted the hydration was a minimum of 31 minutes in length).  However, if the hydration was less than 30 minutes, you cannot code it regardless!  It cannot happen.  I hope this helps


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## mitchellde (Mar 15, 2010)

The hierachy again is for the facility coding as I already pointed out even n the CPT book it states for the physician you use as the initial code the one which fits the reason for the infusion so in the example above you would use initial hydration followed by the susequent push. and if you want to list the push first then fine but you still use the subsequent push code then the initial hydration code.  This is from the CPT book.  But I know I have something else also I just need time to persuse my data base.


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## eadun2000 (Mar 16, 2010)

mitchellde said:


> The hierachy again is for the facility coding as I already pointed out even n the CPT book it states for the physician you use as the initial code the one which fits the reason for the infusion so in the example above you would use initial hydration followed by the susequent push. and if you want to list the push first then fine but you still use the subsequent push code then the initial hydration code.  This is from the CPT book.  But I know I have something else also I just need time to persuse my data base.



Was she not talking about ED facility?  I was under the impression that she was... not pro side.


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## mitchellde (Mar 16, 2010)

No Leslie works on the pro side.


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## LTibbetts (Mar 16, 2010)

Yes, I do work on the pro side but recently we have been asking to take over the facility billing for the injections and infusions as the staff upstairs is not educated in coding and we are ending up fixing all of their mistakes anyway, so we may as well enter them ourselves to save all of the running around.

Deb, you still answered my questions, though, because I did need to know who the heirarchy affects and if it is the facility or not. I am actually coding one right now that came in w/ gastroenteritis and received 2 hrs of hydration before admitted. He also received an IV med, so I use the initial code since this is for the facility side, 96374 and then the 96361x2, right? The other issues we are dealing with here is using the -59 modifier with the IV hydration when the patient has a CT done. That can only be the case when the patient has a CT _w/out _contrast, correct? So, if this pt came in and had a CT w/no contrast, IV drugs x 2, then I can code the CT, 96374-59, and 96375, right? I hate to mess with the -59. What if the pt does have a CT w/contrast but the IV was put in in the ER and the pt received drugs also? Can I use the -59 in this case?

I can't believe how confusing this is. I think I may be starting to get it, though, so thanks everyone for helping me with this. I'm sure it is redundant to you, so I appologize. I need to hear input multiple times before it seems to conceptualize in the head, I guess.


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## mitchellde (Mar 16, 2010)

HYdration before push according to the facility hirearchy.  A therapeutic infusion over hydration so in most cases a push will almost always be subsequent.  Exception... lets say we put in a hep lock or even a main line for the purpose of giving IVpush meds, the the IVpush is initial.  So in the example you have givven it would be the 
96360
96361
96375
 for the CT patient I would not think you need a 59 modifier but I have not checked CCI edits lately, so I would see if the 96374 is bundled and if not then no modifier.
for 2 pushes if they are different meds the 96374 and 96375 if it is the same drug pushed twice in the facility setting 96374 and 96376  If we are adding this to the hydration scenario then
96360
96361
96375
96375 59 (second push new drug)
96376 (second push same drug.

In my CPT book it says that Hydration trumps the push I gave you the quote right out of my book, I check several other sources and they all say the same thing... I am wondering does someone elses book say something different?


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## eadun2000 (Mar 16, 2010)

mitchellde said:


> HYdration before push according to the facility hirearchy.  A therapeutic infusion over hydration so in most cases a push will almost always be subsequent.  Exception... lets say we put in a hep lock or even a main line for the purpose of giving IVpush meds, the the IVpush is initial.  So in the example you have givven it would be the
> 96360
> 96361
> 96375
> ...



In my 2010 CPT book for facility it states "When these codes are reported by the facility, the following instructions apply.  The initial code should be selected using a hierarchy whereby chemotherapy services are primary to theraputic, prophylactic and diagnostic services which are primary to hydration services.  Infusions are primary to pushes, which are primary to injections.  This hierarchy is to be followed by facilities and supersedes parenthetical instructions for add-on codes that suggest an add-on code of a higher hierarchical position may be reported in conjunction with a base code of a lower position.  (For example, the hierarchy would not permit reporting 96376 with 96360, as 96376 is a higher order code.  IV push is primary to hydration.)

That being said, on the facility side, it is always chemo, followed by infusions, followed by pushes, followed by hydration.  However, the only time that I can think of that a hydration is billed primary with an injection is if it is given IM or SQ.  In that case, the hydration is primary.  Otherwise, it is pushes that are primary.  

On the modifier 59 issue, the only time I have ever had to put a modifier 59 on any of the infusions, injections, hydrations is if there is another procedure done; ie chest tube, foley cath, NG tube, etc.  I for the life of me cannot figure out why we have to do it on the foley cath, but it is on the CCI edits so we do it   I have never had to do it because of a CT with contrast or not.  I really hope this helps


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## LTibbetts (Mar 16, 2010)

Deb, in a CPT Ingenix book it states
"96360-96361 IV fluids infusion for hydration:
hierarchy rules for facility setting only:
Diagnositc, prophylactic and theraputic svcs are primary to hydration, Chemo is primary to that, infusions are primary to pushes and pushes are primary to injections."

But as you said before, this is for the faiclity setting. This is a co-workers book and I just found it. The CPT book phrases it differently and maybe that is why I am confused. It does say under the hydration section that the hydration codes are facility reporting only. The same statement is made under the 96365 code set. It also states that if meds are given IV, then the hydration is not seperately reportable.I think that was the source of most of my confusion, especially when pts are coming in specifically to be hydrated but are also receiving zofran, for example. Does this sound right to you?


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## mitchellde (Mar 16, 2010)

Leslie in both your post and the one above it states that "chemo is primary to therapeutic" OK we all agree on that.  Then it says " infusions are primary to pushes, which are primary to injections."  No where in either post does it state that pushes are higher than hydration, Hydration is an infusion so when it says infusions are primary to pushes it includes hydration.  My book clearly makes the statement that hydration goes before pushes.  I do not want to belabor this but it is important to be correct and I think maybe somewhere too much is being read into this.  I looked up several other resources and all said the same thing that hydration goes before pushes.  

Now as far as hydration being separately reportable, it definitely is but you clearly need a dx that will support it, if you started a primary fluid for the purpose of administering push meds then you may not bill the primary fluid as hydration and this happens frequently.  If you can support with documentation and dx that hydration was therapeutic and then we administered push meds then yes you may bill both.  
I have to go with this being the hirearchy until someone can come forth with a better reference that specifically states that push goes before hydration but I do not feel that either of these other references do that.


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