Primary Care Coding Alert

You must meet the 16-minute mark to code for infusions

When your family practitioner performs an infusion involving multiple substances, you need to identify the type of infusion on the claim, or you could risk denials. Further, you-ll need to know which infusion to list as primary, or the claim could wind up being inaccurate.

Initial Codes Represent -Main Reason- for Session

On multiple-substance infusion claims, you should report the initial infusion with 90765 (Intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; initial, up to 1 hour) and +90766 (- each additional hour [list separately in addition to code for primary procedure])--as long as the encounter meets these parameters, says Sarah L. Goodman, CPC-H, CCP, president and CEO of SLG Inc. in Raleigh, N.C.:

- The drug is being administered for therapeutic, prophylactic or diagnostic purposes.
- The infusion lasts at least 16 minutes.
- The infusion is not considered an inherent component of another procedure, such as a CT scan.
- A healthcare professional is continually present during the session.

The physician may report 90766 for -each additional hour- only if the infusion interval is greater than 30 minutes beyond the one-hour increment.

For example, if the patient receives an infusion of a single drug that lasts 1 hour and 45 minutes, the physician would report 90765 for up to one hour and 90766 for the additional 45 minutes.

Don't be fooled: -Initial infusion- does not automatically mean the first drug the FP administers, because payers consider the initial infusion the -main reason- the patient is seeing the FP, says Cindy Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Powder Springs, Ga.

-The chronological order of the drugs, medications and/or substances infused is not important--what is critical is the primary reason for the patient to be there that day,- she says.

Hierarchy Comes in Handy for Infusion Sessions

As a guide, Goodman uses this -unofficial hierarchy- of infusion services she culled from the APC Weekly Monitor. This list could come in handy when deciding how to code multiple infusion claims:

- Chemotherapy infusions
- Chemotherapy injections
- Non-chemotherapy, therapeutic infusions
- Non-chemotherapy, therapeutic injections
- Hydration infusions.

-Regardless of the order in which the FP administers the infusions, report the -initial- code for the service that falls highest on the list,- Goodman says.

Official guidelines: -The initial code is the code that best describes the key or primary reason for the encounter, and should always be reported irrespective of the order in which the infusions or injections occur,- according to Chapter 12, section 30.5E of the Medicare Claims Processing Manual.

Example: The patient presents to the FP's office for chemotherapy treatment, and the FP performs a therapeutic, non-chemotherapy infusion or injection (that is, antibiotics, steroidal agent, antiemetics, narcotics, etc.) followed by a chemotherapy infusion.

According to the hierarchy above, you should report the chemo as the initial infusion and the non-chemotherapy infusion or injection as the subsequent.

One Drug, Then Another Means Sequential Infusion

Once you have decided which is the initial infusion, you-ll need to discover what type of secondary infusion(s) the FP administered. If the FP performs the secondary infusion(s) immediately after the initial infusion, she performed a sequential infusion, Goodman says.

When the physician provides sequential therapeutic infusions, report +90767 (- additional sequential infusion, up to one hour [list separately in addition to code for primary procedure]) for the service.

Remember: -A sequential therapeutic infusion code can only be reported when the initial drug or substance has finished infusing, and a different therapeutic drug, medication or substance begins infusion,- Parman says. Also, you have to have at least 16 minutes of infusion time to report 90767.

All Drugs at Once? Code Concurrent Infusion

There are multiple-substance infusion encounters during which the FP administers all of the drugs to the patient at the same time.

When this occurs, you should report the concurrent infusion code +90768 (- concurrent infusion [list separately in addition to code for primary procedure]) for the secondary substance.

You can report 90768 -when a therapeutic substance is infused in a separate bag at the same time as another therapeutic infusion, or at the same time as a chemo-therapy infusion. This code reports the concurrent infusion of two therapeutic substances, or the concurrent infusion of a therapeutic substance and an antineoplastic substance,- Parman says.

Remember: Use 90768 only once per encounter.

Leave Saline Admin Code Off Claim

One thing that you should never code for when reporting multiple-substance infusion is any fluid the physician uses to administer the IV drugs. Payers always bundle this service into the infusion codes.

-Fluid used as the vehicle for the delivery of other drugs or substances is not separately reported. This would include a -flush bag- or KVO bag of fluid such as saline or D5W,- Parman says.