Oncology & Hematology Coding Alert

Always confirm the route of administration and the duration of infusions.

You may be routinely reporting infusions and injections for drugs for non-chemotherapy agents or highly complex biologic agents. However, you may be losing on deserved revenue. You may not know where you are misreporting simple codes for these procedures. Here are some useful tips that will help make for easy reporting of injections and infusions.

Vital: You should follow two key approaches to successful reporting for injections and infusions:

1. Check route and time to arrive at the right CPT® code.
2. Select infusion codes based on whether the infusion is “initial,” “sequential,”or “concurrent.”

Tip: Do not report the injection and infusion codes when your physician administers contrast for radiological procedures. The administration of contrast is included in the radiological service when you select the ‘with contrast’ codes. Also, do not report these codes for physician billing and reimbursement when these services are performed in a facility setting.

Refer To Route for Correct Code

The first step to accurately report the medication administration requires confirming the route of administration. Check whether administration was rendered through intravenous, subcutaneous, or intra-arterial routes.

Codes for therapeutic/diagnostic or prophylactic (non-chemotherapy) medication intravenous infusions: You would submit the following codes for intravenous infusions:

• 96365, Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour
• +96366, … each additional hour (List separately in addition to code for primary procedure)
• +96367, … additional sequential infusion of a new drug/substance, up to 1 hour (List separately in addition to code for primary procedure)
• +96368, … concurrent infusion (List separately in addition to code for primary procedure).

Look for evidence of intravenous infusions in the clinical note. You confirm intravenous (“IV”) injections or infusions when your physician inserts a catheter into the patient’s vein to administer the drug. Alternatively, your physician may administer the infusion or injection through an existing port in the patient’s vein.

For therapeutic/diagnostic or prophylactic (non-chemotherapy) medication intravenous push (“IVP”), you other more specific codes: When your provider administers a single medication or other substance rapidly into a vein to treat, prevent, or diagnose a condition, you select form the following codes:

• 96374, Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug
• +96375, … each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure).

Note: You should report code 96375 to identify intravenous push of a new substance/drug when your physician provides it as a secondary or subsequent service after a different initial service is administered through the same IV access.

Be specific for intra-arterial route: When your physician administers the injection into an artery, you submit code 96373 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; intra-arterial).

Remember: “If an IVP (chemo or non-chemo) is administered over a period equaling 16 minutes or more, it is reported as an infusion,” says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, Director of Reimbursement and Advisory Services, Altegra Health, Inc. CPT® guidelines state: “Intravenous or intra-arterial push is defined as: (a) an injection in which the individual who administers the drug/substance is continuously present to administer the injection and observe the patient, or (b) an infusion of 15 minutes or less.”

Differentiate Infusions and Injections for Subcutaneous Route Too

Check the following codes for subcutaneous infusions:

• 96369, Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to 1 hour, including pump set-up and establishment of subcutaneous infusion site(s)
  
• +96370, … each additional hour (List separately in addition to code for primary procedure)
  
• 96371, … additional pump set-up with establishment of new subcutaneous infusion site(s) (List separately in addition to code for primary procedure)
  

Note: You submit code +96370 and +96371 in conjunction with 96369. You report +96370 for infusion intervals of greater than 30 minutes beyond 1 hour increments. You submit codes 96369 and 96371 only once per encounter.

What are subcutaneous infusions? You can confirm a subcutaneous infusion when the physician administers the drug just below the skin. The common sites for subcutaneous infusions are shoulder, upper arm, abdomen, and thigh.

Differentiate infusion vs injection: For subcutaneous injections, you turn to code 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular).

Tip: Report code 96372 for infusions of 15 minutes or less. This infusion may be given via subcutaneous or intramuscular routes.

It is Mandatory to Document the Time of Infusions

When reporting add-on codes +96366 and +96370, they are to be submitted for each additional hour. Additionally, the documentation must support an interval of greater than 30 minutes beyond one hour increments.

Follow This Example to Test Your Understanding

Here is an example to help you understand how to select the most appropriate code and make your claims clear.

You may read that your physician administered 250 mg of Solu-Medrol by intravenous infusion over two hours. In this case, you will code for the procedure in two parts (i.e., a code each for the first and the second hour of infusion).

For the first hour of infusion, you submit one unit of 96365. For the second hour of infusion, submit code +96355. In addition, you report two units of J2930 (Injection, methylprednisolone sodium succinate, up to 125 mg) to equal the 250mg given.

Editor’s note: Read more about chemotherapy and complex drug administration in the next issue of the Oncology Coding Alert, Volume 17 number 2.