Presented by

Karen Kvarfordt, RHIA, CCS-P, CCDS President, DiagnosisPlus, Inc.

“Finding HealthCare Solutions…Together”PO Box 2521Twin Falls, ID 83303(208) 423-9036

Daylee1@mindspring.com

2014 Drug Admin CPT codes and rules Same ‘Renumbered’ CPT codes from

2009 Review clinical scenarios related to some

of these codesReview documentation requirements and

better practicesTime Documentation (start & stop)Using Modifier -59 with Drug Administration Services

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Nope, it isn’t pharmacy. Just revenue, not cash.

Nope, it isn’t supplies either. Just revenue, not cash.

Yes, it is NursingNursing! They are finally able to bill specifically for the services they provide in an outpatient setting. It’s about time!

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High area of lost revenue: ER to OBS, Direct admit to OBS, and OR to OBS.

Co-mingling inpt and obs beds = highly problematic time charting for drug administration.

Focus nursing on charting start and stop times to capture every minute.

Charge capture is highly complex for nursing.

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Observation – IV Infusions, Injections, Blood Transfusions, Outpatient Procedures

IDEA: Identify an owner to charge capture on the unit or move to Charge Capture Analyst.

IDEA: Drug Administration & bedside procedures = major lost revenue.

IDEA: Create Observation Attack Team to audit daily for billable time, G code, and charge capture for nursing procedures, Condition Code 44 = 1 1 touchtouch.

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Initial/primary reason for visit

Use 9xxxx codes for all payers. C code/pump for Medicare only

Once determined, initial/primary visit code (hydration, therapeutic, chemo)- then use subsequent CPTs for additional services

All outpatient areas are impacted: ER, Observation, Hospital Based Clinics (HBC)

IDEA: Nursing takes ownership for charting ‘stop and stop’ times per CPT

IDEA: Create Charge Capture Analyst position

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Create a stamp for Drug Adm start and stop times. (Could do

recovery & 02 as they are timed charges) Use the stamp for billable time IV Hydration Infusion ______ _______ ______ _____ ______ (multiple lines) Start Stop Date Dept Initials IV Therapeutic Infusion _____ ________ _______ ______ ______ (multiple lines) Start Stop Date Dept Initials

Remember! Time continues from the Emergency Room to the Observation/Outpatient areas

No major changes in OPPS rulesPer-service APC payment continuesFinancial impact related to drug

administration services will vary based on your mix of

services, hours of infusion, and internal charge capture practices

Majority of drug administration changes due to additional parenthetical notes

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Need to continue following CPT guidelines and instructions and MUST review CPT descriptors and parenthetical notes carefully!

From the hydration, therapeutic, prophylactic, and diagnostic injections & infusions section:

“Physician work related to hydration, injection, and infusion services predominantly involves affirmation of treatment plan and direct supervision of staff. These codes are not intended to be reported by the physician in the facility setting.”

Note: The above language was new in 2008… sets precedent regarding facility vs. physician reporting.

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• Still the same! CPT has outlined a hierarchy from Nov 2005 CPT Assistant Takes the guess work out of trying to figure out

which drug admin service should be the “initial”, subsequent, etc.

• “InitialInitial” code should be selected using a hierarchy whereby: Chemotherapy services are primary to therapeutic,

prophylactic, and diagnostic services which are primary to hydration services.

Infusions are primary to pushes, which are primary to injections.

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Question: Does the fact that infusions are primary to pushes mean that hydration is primary to a push (IV push injection)?

Answer: No, because the first sub-bullet indicates that therapeutic, prophylactic and diagnostic services are primary to hydration services; an IV push is considered a therapeutic, prophylactic, or diagnostic service, therefore it is primary to hydration.

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The CPT statement is: “The initial code should be selected using a hierarchy whereby chemotherapy SERVICES are primary to therapeutic, prophylactic, and diagnostic SERVICES, which are primary to hydration SERVICES. Infusions are primary to pushes, which are primary to injections.”

Within each “code set” have a further breakdown of the type of delivery/route/method (infusion, then the push, then the injection).

Since hydration is the last code set, and there is only one method (infusion), it would always be secondary to any other medication administrations.

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When administering multiple infusions, injections or combinations, only 11 initial service code should be reported, unless protocol requires that 2 separate IV sites must be used and is medically necessary.

If a significant separately identifiable E&M service is performed, the appropriate E&M service code should be reported using modifier -25 in addition to 96360-96379. For same day E&M service a different diagnosis is not required.

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If performed to facilitate the infusion or injection, the following services are included and are not separately billable:

a. Use of local anesthesiab. IV startc. Access to indwelling IV,

subcutaneous catheter or portd. Flush at conclusion of infusione. Standard tubing, syringes and

supplies

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Codes allall deleted and moved in front of the Chemotherapy CPT codes (renumberedrenumbered) in 2009 – still the same for 2014

Same 2014 CPT Codes: 9636096360 – 9637996379Same Heading:

Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions, and Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration

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Parenteral administration non-radionuclide anti-neoplastic

Anti-neoplastic for non-cancer diagnoses◦ i.e., Cyclophosphamide for auto-immune

conditions Monoclonal antibody agents

◦ Other biologic response modifiers (BRM)

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Very complex work and monitoring way beyond a ‘normal’ infusion◦ Possibility of severe reactions◦ Advanced practice training◦ Special consideration for prep, dosage,

disposal◦ Frequent monitoring

Changes in infusion rate Prolonged presence of nurse Frequent communication with physician

◦ If performed to facilitate infusion or injection, these are included and are not separately billable

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CPT 9636096360: Intravenous infusion, hydration; initial, 31 minutes to 1 hour31 minutes to 1 hour

Must reach 31 minutes in order to bill infusion In 2007 we had 16 minutes (history tidbit)

Do not report hydration infusions of 30 minutes or less! No CPT code for this!

Hydration – IV infusion to consist of a pre-packaged fluid and electrolytes (i.e. normal saline, D5 ½ normal saline +30mEq KCL/liter), but are not used to report infusion of drugs or other substances.

“TKO” (to keep open) & “KVO” (keep vein open) cannot be charged.

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ER patient presents with a laceration to the forehead

ServiceService TimeTime DescriptionDescription 2014 CPT Code2014 CPT Code

Laceration repair

5:30 Laceration repair with Xylocaine

Depends on documentation

IVPB 5:00 – 5:20 Normal saline wide open

No CPT code

IVP 6:00 Morphine 96374 x 1

Blood transfusion

7:00 – 9:30 Transfusion2 units whole

blood

36430 x 1P9010 x 2

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CPT 9636196361: Intravenous infusion, hydration; each additional hour each additional hour

List separately in addition to code for primary procedure)Add-on code (+)

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CPT 9636596365: Intravenous infusion, for therapy, prophylaxis, or diagnosis; initial, initial, up to 1 hourup to 1 hour

CPT 9636696366: Intravenous infusion, for therapy, prophylaxis, or diagnosis; each each additional hour additional hour List separately in addition to code for primary

procedure).Add-on code (+)

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CPT 9636796367: Intravenous infusion, for therapy, prophylaxis, or diagnosis; additionaladditional sequential infusionsequential infusion, up to 1 hourList separately in addition to code for primary

procedure

Coding Tip! Do not report more than once per sequential infusion of the same mix.

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CPT 9636896368: Intravenous infusion, for therapy, prophylaxis, or diagnosis; concurrent infusion concurrent infusion

List separately in addition to code for primary procedure

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CPT 9636996369: SubcutaneousSubcutaneous infusion for therapy or prophylaxis (specify substance or drug); initialinitial, up to 1 hour, including pump set-up and establishment of subcutaneous infusion site(s).

CMS Guidance: For infusions of 15 minutes or less, report with CPT code 96372

Additional guidance: Involves the placement of multiple subcutaneous

accesses to infuse immune globulin Includes an infusion pump to administer the infusion

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CPT 9637096370: SubcutaneousSubcutaneous infusion for therapy or prophylaxis (specify substance or drug); each additional hour each additional hour List separately in addition to code for primary

procedure

Add-on code (+) = Must be reported with CPT code 96369

For infusions greater than 30 minutes beyond one hour increments

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CPT 9637196371: SubcutaneousSubcutaneous infusion for therapy or prophylaxis (specify substance or drug); additional pump set-up with additional pump set-up with establishment of new subcutaneous establishment of new subcutaneous infusion site(s).infusion site(s).

Report with CPT code 96369Report 96371 only 1 time per dayCMS Guidance: “Captures the practice

expense of obtaining additional accesses and the set up of a pump for infusions in larger individuals”.

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CPT 9637296372: Therapeutic, prophylactic or diagnostic injection; subcutaneous or intramuscular (SC/SQ or IM)

Only CPT code that does NOTNOT follow the CPT hierarchy – rules do not apply

Can report multiple SC/SQ/IM injections of the same substance/drug

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CPT 9637396373: Therapeutic, prophylactic or diagnostic injection, intra-arterialintra-arterial

CPT 9637496374: Therapeutic, prophylactic or diagnostic injection; IV push, IV push, single or initial drugsingle or initial drug

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CPT 9637596375: Therapeutic, prophylactic or diagnostic injection; each additional each additional sequential IVP of a sequential IVP of a newnew substance/drug substance/drug

List separately in addition to code for primary procedureAdd-on code (+)

96374 + 96375

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CPT 9637696376: Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential IV push of each additional sequential IV push of the the samesame substance/drug provided in a facility substance/drug provided in a facilityBe careful! Code cannot be reported if a push of the Code cannot be reported if a push of the

same substance or drug occurred within 30 minutes same substance or drug occurred within 30 minutes (pushes of same substance or drug must be “31 (pushes of same substance or drug must be “31 “minutes apart)“minutes apart) Ex: Four hourly IVPs of Demerol would be reported as 96374 x

1 & 96376 x 3 as long as the time requirement is metIs the time documented in your medical record?

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Report multiple individually prepared individually prepared administrationsadministrations as individual drug administrations.

If the drug or substance is prepared one time and then administered in portions, report the administrations as only oneone administration (i.e. CPT 96374).

If the clinician administers a 2nd, separately prepared same drug in portions, this would equal a single admin of the same drug beyond a

30-minute interval (CPT 96376).

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Medical record documentation by the clinician does not easily allow a coder to determine whether the IV pushes were individually prepared or administered in portions.

Still no separate APC payment assigned to this code for 2014.

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ServiceService TimeTime DescriptionDescription 2014 CPT Codes2014 CPT Codes

IVP 1000 Lasix 96374 x 1

IVP 1110 Lasix 96376 x 1

IVP 1300 Lasix 96376 x 1

IVP 1500 Lasix 96376 x 1

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ServiceService TimeTime DescriptioDescriptionn

2014 CPT Codes2014 CPT Codes

IVP 1000 Lasix 96374 x 1

IVP 1018 Lasix No code – Why?

IVP 1300 Lasix 96376 x 1

IVP 1500 Lasix 96376 x 1

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Initial Code that best describes the key or primary reason for

the visit One code in each category of IV infusion and IV push

drug administration codes has been designated as the “initial” service

Order of service delivery does NOT determine what is “initial”

Only one “initial” service should be reported per encounter UNLESS: Protocol requires two separate IV sites Multiple encounters are provided on the same DOS Other drug administration services are also provided by a

different route other than IV infusion or IV push

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Question: How is the initial service selected? Answer: The “initial”“initial” code that best describes

the key or primary reasonkey or primary reason for the encounter should always be reported regardless of the order in which the infusions or injections were given.This was not always clear in the past, but now

the 2014 CPT book makes it explicit with a hierarchy!Chemo infusionsChemo injectionsNon-chemo, therapeutic infusionsNon-chemo, therapeutic injectionsOther injectionsHydration infusions

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Sequential/SubsequentSequential/Subsequent Add-on codes (think “one after another” or

“before or after the initial drug service”)Should be used in addition to an “initial”

code and the order of the services given does not matter

Reported once per encounter for the same infusate mix; additional hours reported with additional hours therapeutic infusion code (96366); and it is okay to report multiple sequential infusion codes if multiple different drugs are given

Infusion must be 16-91 minutes…apply the infusion time requirement

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Question: How should an IV infusion of the same infusate that’s given multiple times during 1 visit be reported?

Answer: For example, calcium and magnesium are combined with D5W in an IV bag and one 20 minute infusion is given pre-chemo and one 20 minute infusion is given after chemo. This infusion would be billed as one sequential infusion, up to 1 hour (96367). The two 20-minute infusions of calcium/magnesium would be added together for a total of 40 minutes.

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Concurrent (think “at the same timeat the same time”)Add-on code when multiple infusions are

provided simultaneously through the same IV line, even with different bags.

No code for concurrent administration of chemo drugs, but if it does happen, then the unlisted chemo admin code 96549 should be reported.

Multiple substances mixed in one bag are considered to be one infusion, not a concurrent infusion.

There is no concurrent code for hydration.Still no separate payment for the concurrent

infusion code (96368) for 2014.

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If a separate venous access site is started for hydration along w/ another venous access site for a therapeutic infusion, report an “initialinitial” code for the hydration andand the appropriate “initialinitial” code for the other infusion access site.

However, the CPT Manual makes it clear that hydration running concurrently through the samesame access site is still not separately reportable.

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Selecting what the “initial” service is less of a mystery now! Yeah!Fairly easy for scheduled clinic/infusion

therapy and oncology patients.Not as easy for unscheduled/ER visits so follow

the hierarchy & read the CPT parenthetical notes.

Remember, hydration can be reported with other drug admin services, but it will typically not be reported with the “initial” service code.

Can’t always rely on an edit to tell if what you are charging/coding is correct or incorrect.

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IV infusion of short duration is still defined as 15 minutes or less - report with an IV push injection code.

Initial or 1st hour of infusion is from 16 to 90 minutes (applies to therapeutic infusions but not to hydration).

Additional hours of infusionReport add-on codes for additional hours of

infusion (beyond the 1st hour) only after more than 30 minutes have passed from the end of the previously billed hour (i.e. 91 minutes would allow an additional hour to be charged).

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Per AMAAMA – “Infusion time is measured when the infusate is actually running: pre and post time are not counted. It is recommended to document BOTH infusion start and stop times.”

Per CMSCMS – “Hospitals are to report codes according to CPT instructions. Are to use the actual time over which the infusion is administered to the patient for time-specific drug administration codes.”

Remember that a reviewer must be able to determine the actual amount of time a medication infused from the records, not just the ‘ordered’ infusion time.

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Do you report an infusion, injection, or nothing when the stop time is missing? CMS has stated that a short-duration infusion (i.e. less than

15 minutes) can be reported as an IV push injection……. therefore, if there is no stop time, would the infusion automatically be 15 minutes or less……since you don’t know if it was more?

CMS does not state anything about what can/cannot be reported if an explicit “stop” time is missing…..but several FIs have indicated that an IV push injection can be reported.

Remember, if there is no stop time for hydration you cannot report anything unless 30 minutes is charted.

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Better practice is to require start and stop require start and stop times for all drug administration servicestimes for all drug administration services!

Regardless of how the charges are created, nursing's charting of start & stops does not change.

Financial impact of “down-coding”CPT 96365 & 96366 CPT 96374 & 96375

National APC payment $129$129 (1st hour infusion) vs. $36 $36 (IV push) Plus potential loss of any additional hour(s) @ $25 $25 per hour

Makes a huge difference to the bottom line!Makes a huge difference to the bottom line!

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If the drug administration service is typically performed pre- or post-procedure, then you do not separately report.Examples: Infusion of anesthetic for surgery; pre-op

antibiotic injection/infusion; post-op pain and/or nausea injections; injections during CPR; injections for sedation analgesia

If the drug administration services is not typical for the procedure, then you do report it separately.Examples: Anti-thrombolytic injection either pre- or post-

surgery; anti-hypertensive injection

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ER to OBS ◦Handoff from ER to OBS – Do you maintain 2

separate nursing documentation tools? Are the drug administration services being captured correctly from the ER to OBS?

PP (Post-Procedure) to OBS◦Cannot bill observation until 4-6 hours of

routine recovery has passed Direct Admit to OBS

◦Nursing needs to document all drug administration services as well as any bed-side procedures

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Modifier -59 must be used in specific situations and you may find that you are using them more frequently than what was initially expected.

Use Modifier -59 if two vascular access sites are started

Use Modifier -59 if multiple encounters occur on the same date of service

CCI edits for drug admin are being applied in full, therefore the traditional rules for modifier -59 are in effect; no code pairs are exempt from the CCI edits

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Most frequent CCI edit: When twotwo initial service codes are paired together you will receive an edit message:““Code 96365 is a component of code 96413 but a Code 96365 is a component of code 96413 but a

modifier is allowed in order to differentiate between modifier is allowed in order to differentiate between the services provided.” the services provided.”

You can only have oneone “initial” service per IV site per encounter unless multiple lines are started.

Just because the edit appears does not mean you should add it just to get it out the door!

HIM department should be the ones to research WHY there was a rejection. NEED THE MEDICAL NEED THE MEDICAL RECORDRECORD!

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What happens when the visit crosses the midnight What happens when the visit crosses the midnight hourhour??

On the January 2008 Open Door Forum call, CMS indicated that multiple “initial” service CPT codes should not be reported for a single encounter, even if the encounter crosses dates of service.

Do not “reset” the initial service CPT definitions just because the encounter has crossed the midnight hour.

Example: If a patient is in the ER on 4-10-13, and IV hydration is started @ 10:00pm and continues until 4-11-13 @ 2:00am, how would this look?

96360 x 1 on 4-10-13 96361 x 1 on 4-10-13 96361 x 2 on 4-11-13

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2014 should be easier since very little has changed. Just look for further guidance in the parenthetical notes!

Only sure way of knowing how you are doing with reporting drug administration services is to conduct an audit. Measure compliance!

Audit and monitor your records now for success in 2014! It’s never too late!

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2014 OPPS Final Rulewww.cms.hhs.gov/HospitalOutpatientPPS/HORD

2014 CPT Book

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Karen Kvarfordt, RHIA, CCS-P, CCDSPresident, DiagnosisPlus, Inc.P.O. Box 4865486 Country Club DrivePocatello, ID 83204(208) 221-5486Fax: (360) 234-7590diagnosisplus1@live.comwww.arsystemsdayegusquiza.com

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