Neurosurgery Coding Alert

Read this if you ever get confused about proper injection/infusion types.

Coding for injections and infusions might seem like a simple exercise, but there’s more to it than the codes. You’ll need to know the different types of injections/infusions and the hierarchy for reporting these services. Get one of these elements wrong, and your claim could be coming back unpaid.

Don’t worry: Stay out of payers’ crosshairs with this primer on key terms and concepts for injection/infusion coding, from Michele M. Stevens, CPC, CPMA, AAPC Fellow. During her HEALTHCON 2021 Dallas session “Infusion, Hydration, Injection Coding,” Stevens walked attendees through the definitions of the infusion/injection terms that so often pop up in CPT^® code descriptors.

Here’s what she had to say.

Know Different Injection/Infusion Types

There will be key terms in the notes of any injection/infusion claim that coders must know before they can even hope to select the proper code. Check out Stevens’ definitions of the major injection/infusion types you’re likely to see:

• Chemotherapy: “A type of cancer treatment that uses one or more anti-cancer drugs as part of a standardized chemotherapy regimen.”
• Infusion: “The slow injections of a substance into a vein or tissue.” This process could take hours.
• Therapeutic: “Of or relating to the medical treatment of a disease or condition, such as rheumatoid arthritis.”
• Push: “An IV push, or bolus, is a rapid injection of medication. A syringe is inserted into your catheter to quickly send a one-time dose of medication into your bloodstream.”
• Hydration: “IV rehydration is a treatment for fluid loss in which a sterile water solution containing small amounts of salt or sugar is injected into the patient’s bloodstream.”

Know Hierarchy of Injections/Infusions

You should also know which types of injections/infusions are the most specialized, and the ones that are more general. That way, you’ll know whether or not one service is included in the other: for instance, hydration is included in the work units of most chemotherapy codes. So, you wouldn’t report hydration separately for a patient undergoing chemotherapy.

Follow this hierarchy for injections/infusions, showing you the order in which you should consider injections/infusions (in descending order). If you’re unsure how to prioritize injections/infusions on a claim, rely on this hierarchy:

• Chemotherapy
• Chemotherapy IV push
• Chemotherapy injection
• Therapeutic, prophylactic, or diagnostic infusion
• Therapeutic, prophylactic, or diagnostic push
• Therapeutic, prophylactic, or diagnostic injection
• Hydration

Know What Questions to Ask

If you’re unsure of what type of injection/infusion the patient received, Stevens recommends you look at the claim and ask these questions about the service:

• Why is the patient here?
• What did the patient receive?
• How was it given?
• How long did it take?

Once you have those questions answered, it should be much easier to arrive at the type of injection/infusion you need to code for.

Know Documentation Requirements

Stevens stressed the need for strict documentation on your injection/infusion claims to avoid the ire of payers. On your injection/infusion claims, documentation should include:

• Drug/substance administered;
• Mode of administration (infusion, IV push, intramuscular injection, subcutaneous injection, etc.);
• Access site (IV at right antecubital, port, etc.);
• Start and stop times;
• Rate of administration; and
• Dose and volume of drug administered.