Inpatient Facility Coding & Compliance Alert

Question: A patient's husband brought her to the ED because of chest pain; previous records showed she had a history of sickle cell disease. The ED physician ordered multiple labs including a CBC, CMP, and PT/PTT/INR. He also ordered and read/interpreted a two-view chest X-ray. The patient received narcotics and intravenous fluids (Dilaudid, Zofran, and saline hydration) during the course of care (Dilaudid was administered at two separate times).

The patient was discharged after her pain was brought under control. Her discharge diagnosis was sickle cell disease with vaso-occlusive crisis and chest pain without evidence of acute chest syndrome. The ED physician documented a detailed history and examination. What should we report for the facility services?

North Dakota Subscriber

Answer: You'll need to report several codes to have a complete facility claim:

• Using a typical facility intervention based model to determine an E/M level, assign 99284 (Administration of infusions or parenteral meds and two types of diagnostic tests- labs & chest x-ray)
• Link modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to 99284 to show that the E/M, therapeutic injections, and hydration were separate services.
• 96374 (Therapeutic, prophylactic, or diagnostic (specify substance or drug); intravenous push, single or initial substance/drug) to represent the IVP of Dilaudid
• 96375 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug [List separately in addition to code for primary procedure]) to represent the sequential IVP of Zofran
• 96376 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug [List separately in addition to code for primary procedure]) to represent the sequential IVP of Dilaudid
• 96361 (Intravenous infusion, hydration; each additional hour [List separately in addition to code for primary procedure]) to capture the intravenous infusion of normal saline. If documentation shows that the saline administration lasted more than an hour, you'll report 96361 for each hour.
• Codes for laboratory and radiology services as appropriate.

Remember: Observe the appropriate hierarch when reporting hydrations, injections, and infusions. Thus, you should only report one primary code. The hierarchy is as follows:

Infusion (96365) -- Injection (96374) -- Hydration (96360)

Also include the appropriate diagnosis codes to support medical necessity:

• 282.62 (Hb-SS disease with crisis) linked to the E/M service, hydration, and injections
• 786.50 (Chest pain, unspecified) linked to the X-ray.