Auditing Infusions, Hydrations, and Injections

If your facility and/or practice is providing infusion, hydration, and injection services, they should be included in your annual compliance auditing plans to ensure proper coding guidelines are being followed and documentation education is not necessary to assist with any loss of revenue gaps.

Infusion, hydration, and injection services follow coding guidelines specific to orders placed and often time-based CPT codes. Understanding the hierarchy for these services is the first step in ensuring proper CPT assignment along with the document requirements. Knowing the difference between your initial, sequential, and concurrent CPT codes and how each is used will provide accurate code assignment.

Chemotherapy infusion, chemotherapy push, and chemotherapy injections sit at the top of the hierarchy tree above therapeutic, prophylactic, or diagnostic infusion; therapeutic, prophylactic, or diagnostic push; and therapeutic, prophylactic, or diagnostic injections while hydration resides at the bottom. Understanding which initial service is coded allows proper selection of your initial infusion, push, or hydration CPT code. The initial service best describes the reason for the encounter or why the patient is being seen. It is important to note that hierarchy does not apply to subcutaneous or intramuscular injections.  There is only one "initial" service per patient encounter unless two separate IV sites are medically used/necessary or the patient returns for a separate and medically necessary, reasonable encounter on the same day.  A 59 modifier would need to be applied to the "second" initial service on that day.

Documentation required to ensure correct code assignment includes:

Ensure that proper use of JW modifier was applied for all drug wastage.  Any services leading up to the infusion and following the infusion have been included in the infusion code services and are not reported separately. Infusion and/or injection services that are included as part of the operative services under the outpatient Prospective Payment System (OPPS) are not separately billable include the following:

Time Required for Infusion:

1st Hour: 16 - 90 minutes
2nd Hour: 91 - 150 minutes
3rd Hour: 151 - 210 minutes

Ensuring that sequential infusions are used for medications that were truly infused back-to-back:

You have two or more different drugs flowing one after another through that same IV access site with clinical reasons for them being done sequentially versus concurrent. Concurrent infusions occur when multiple therapeutic or diagnostic medications (not hydration fluids) are infused simultaneously through separate bags through the same vascular access site. This CPT code is only reported once per date of service.

Time Required for Hydration:

1st Hour: 31 - 90 minutes
2nd Hour: 91 - 150 minutes
3rd Hour: 151 - 210 minutes
Coding hydration services requires ensuring that medical necessity has been supported within the encounter documentation. Each MAC has their own policy and guidelines and they should be reviewed to ensure compliance as nausea alone does not implicate fluid volume depletion nor support necessity of fluid repletion. Medical necessity is supported in the evaluation performed by the provider and documentation of their assessment should describe symptoms warranting hydration, such as abnormal laboratory studies (elevated BUN, creatinine, glucose, or lactic acid). Example of a medical necessity note from NGS: 

MN: the rate of the infusion is important in determining hydration therapy. Typically at least 100 to 125/cc up to wide open IV flow. If ordered below 100/cc, physician documentation must indicate that it is hydration and why a slower rate was ordered. Example: A patient with CHF or an elderly patient may need slower administration.

When auditing vaccine administration, it's important to note the age of your patient, payer, and if counseling was provided as part of the encounter or if it was a nurse-only visit for injections.  Knowing the difference between all of these vaccine administration CPT codes will ensure that your facility and/or practice is not leaving any revenue behind.

By Michele Stevens

NAMAS delivers preparation classes for the AAPC CPMA® exam, as well as continuing education opportunities for medical auditors. Other professionals, such as coders, practice managers, physicians, mid-level providers, and compliance officers, find our educational programs extremely beneficial in improving the effectiveness of their work.

Sources: CPT, CMS, National Government Services, CPT Assistant Sept 2017, National CCI 1/1/2016