Primary Care Coding Alert

Resolve to break down IV infusion therapy based on the bag's contents, not insurer

You can start 2006 off on the right foot by submitting flawless hydration and medicine infusion claims--just be sure you are using these newly updated guidelines.

CPT 2006 replaces the 2005 universal infusion codes with six new codes. Similar to last year's G code structure, -the new CPT codes make the distinction between the reasons the physician gives the fluids--hydration (90760-90761) versus treatment (90765-90768),- says Patricia Davis, CPC, business office supervisor at Middlesex Health System Primary Care in Middletown, Ct. Instead of using a single code set (90780-90781), CPT breaks intravenous therapy into two buckets:

- 90760-90761 for hydration
- 90765-90768 for therapy, prophylaxis and diagnosis.

The new structure not only mirrors CMS- infusion codes G0345-G0350 but also replaces them. -The good news is that we can use the same therapy codes, regardless of insurer,- Davis says. In 2005, you had to use CPT codes for private payers and HCPCS codes for Medicare carriers. Let these three examples steer your infusion coding for 2006 claims.

Look for 3 Details That Characterize 90760-90761

You can arrive at the correct therapy code if you identify the infusion's purpose, the FP's whereabouts, and the therapy's duration. Look for these three details in the following example to guide you in coding the scenario: 

Example 1: An FP directly supervises an IV infusion of 500 cc of normal saline solution to a patient with diarrhea and vomiting. Documentation states the infusion administration occurs from 2:20 to 3 p.m.

The infusion's purpose: Because the IV infusion is for hydration, you should consider two time-based CPT codes. Codes 90760-90761 describe IV infusion of a common pre-packaged saline solution, Davis says. In these cases, staff members grab the bag, hang it and hydrate the patient.

The FP's whereabouts: The above scenario specifically notes that the infusion occurs under direct physician supervision, which means the FP is in the office or the hospital, but not in the exam room or bedside, throughout the procedure. Therefore, the encounter meets CPT's 90760-90761 requirement of direct physician supervision.

The therapy's duration: The therapy's time further narrows down hydration therapy codes. If the service is longer than 15 minutes, you should report the first hour of hydration infusion with 90760 (Intravenous infusion, hydration; initial, up to one hour). If the FP directly supervises the therapy for an additional 30 minutes or more, you should also report +90761 (... each additional hour, up to 8 hours [list separately in addition to code for primary procedure]).

Solution: Because the IV infusion in the first example lasts less than one hour, you should report the service with 90760. 
 
Old method: In 2005, you should have coded hydration therapy with a general CPT infusion code or a HCPCS level-II G code. For a patient with private insurance, the applicable codes would have been 90780 (Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour) and +90781 (- each additional hour, up to eight [8] hours [list separately in addition to code for primary procedure]). For Medicare carriers, you should have used G0345 and G0346, whose descriptors are identical to 90760 and 90761.

Exclude Separate E/M, Solution From Infusion Bundle

Make sure that you base hydration time only on the infusion's administration time, which equates to 40 minutes in the above therapy case. -Services leading up to and concluding the infusion have been included in the infusion service code and are not separately reported,- states the AMA in CPT Changes 2006: An Insider's View.

The codes also include line placement and inherent IV-related supplies, says Richard H. Tuck, MD, a coding consultant and speaker based in Ohio. -But you may report a significant, separately identifiable E/M service by using modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service),- he says.

The infusion codes do not, however, include the IV bag's contents. For the solution, assign the appropriate J code, such as J7050 (Infusion, normal saline solution, 250 cc). To bill 500 cc as in the hydration scenario, code -2- units of J7050. Warning: Report the supply code only if your physician provides the solution.

Don't forget: You should link the hydration code to the ICD-9 code for dehydration (276.51, Volume depletion; dehydration). Remember, this code requires a fifth-digit subclassification, effective Oct. 1, 2005.
 
Pinpoint Drug Infusion's 3 P-s

In 2006, you can also ignore the patient's insurer when coding IV infusion involving medicine. In these cases, you should instead focus on the same three items that you looked for when reporting hydration therapy. Solve the following case by asking yourself about the scenario's three P-s: purpose, physician presence, and procedure time.

Example 2: An FP directly supervises IV infusion of Rocephin for a child with pneumonia. The IV infusion administration lasts 30 minutes.

Purpose: Because staff use the IV to administer something other than pre-packaged fluid and/or electrolyte solutions--in this case Rocephin or an antibiotic--you should report therapeutic, prophylactic and diagnostic infusion codes 90765-90768 rather than hydration therapy codes 90760-90761. Although FP coders will primarily use 90760-90761, you should instead assign 90765-90768 when an IV bag contains medication, says Daniel S. Fick, MD, director of risk management and compliance for the College of Medicine faculty practice at the University of Iowa in Iowa City.

Physician presence: The note indicates that the FP provides direct supervision throughout the infusion as CPT's drug infusion codes require. So the procedure qualifies for 90765-90768.

Procedure time: When the infusion involves administering a single drug, choosing the correct therapeutic, prophylactic or diagnostic infusion is relatively simple. -You should assign 90765-90766 based on the infusion's duration,- Fick says.

Because the infusion in the above scenario lasts less than one hour, you should report 90765 (Intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; initial, up to one hour). If the infusion lasts more than 30 minutes longer than one hour, also use +90766 (- each additional hour, up to 8 hours [list separately in addition to code for primary procedure]).
 
In addition to 90765, you should assign J0696 (Injection, ceftriaxone sodium, per 250 mg), if the office supplies the drug. For the ICD-9 code, use 486 (Pneumonia, organism unspecified).

Take 2 More Steps to Code Multiple Medicine

For infusions that involve more than one drug, two add-on infusion codes may come into play. These cases require identifying the initial or main substance, as well as the drugs- administration order.

Example 3: After receiving an allergy injection, a patient goes into anaphylaxis. To treat the individual's severe hypotension, the FP directly supervises IV infusion of 40 mcg of epinephrine for 30 minutes. Immediately following the initial infusion to reduce the patient's risk of recurring or protracted anaphylaxis, the physician has the nurse intravenously administer 250 mg hydrocortisone, which takes 15 minutes.

Step 1: Identify the main substance. Because the main drug that the IV infusion delivers is epinephrine, you should report that as the initial infusion. Based on the infusion time, you should assign 90765.

Step 2: Capture the additional drug. You should also code for administration of the second drug with add-on code +90767 (- additional sequential infusion, up to one hour [list separately in addition to code for primary procedure]) if the infusions occur sequentially and involve separate bags. When a staff member provides multiple IV drugs to a patient at the same time through the same IV line, you should instead report +90768 (- concurrent infusion [list separately in addition to code for primary procedure]) in addition to the initial infusion code(s) 90765-90766. 
 
Code the drug supply with the appropriate J code. For the epinephrine, use J0170 (Injection, adrenaline, epinephrine, up to 1 ml ampule). If the FP provided Solu-Cortef, assign J1720 (Injection, hydrocortisone sodium succinate, up to 100 mg). Link 90765 and 90767 to 999.4 (Complications of medical care, not elsewhere classified; anaphylactic shock due to serum).

Warning: You shouldn't separately report fluid used to administer drugs, says Cindy Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Powder Springs, Ga., and president of the AAPC National Advisory Board. -The CPT guidelines classify this as incidental hydration.-