Post on 09-Apr-2020
AUDITING OUTPATIENT
INFUSION CENTERS AMY LEE SMITH, CIA, CRMA, MBA,
CPC, CPC-H, CPMA
SENIOR MANAGER, INTERNAL AUDIT
BON SECOURS HEALTH SYSTEM, INC.
AHIA 33rd Annual Conference – September 21-24, 2014 – Austin, Texas
www.ahia.org
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Objectives
Describe the outpatient infusion center’s operational
role in a health system
Explain the complex billing and coding rules for
outpatient infusion
Share tips and tricks for conducting a valuable
outpatient infusion audit
Design a comprehensive audit plan for outpatient
infusion centers
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Disclaimer
CPT codes, descriptions and other data are
copyrighted by the American Medical Association.
All rights reserved. CPT is a registered trademark
of the American Medical Association.
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Outpatient Infusion Centers
Typically established for convenience of patients
requiring frequent medication infusions or blood
transfusions
May be physician or hospital owned, or free-
standing
Usually do their own scheduling, registration,
insurance verification, charge entry, medical record
storage, release of information, etc.
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Infusion Center Coding & Billing 5
Tips for Infusion Coding Audits
Enlist assistance from coder when auditing
charges/codes
Study section introduction(s) in current CPT book
Learn and understand coding rules and National
Correct Coding Initiative (NCCI) edits
Employ CAATs for data mining
Work closely with infusion staff to locate and
understand documentation
When in doubt, ASK QUESTIONS!!
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What’s Included in Drug Administration
The following services are included in all of the drug administration codes, and are not separately reportable:
Use of local anesthesia
IV start
Access to indwelling IV, subcutaneous catheter or port
Flush at conclusion of infusion
Standard tubing, syringes and supplies
The chemotherapy administration codes also include preparation of drugs/agents and any fluids used to administer the chemotherapy; these are not separately reportable.
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Drug Administration Coding Basics 8
3 categories of drug administration:
Hydration
Therapeutic/Prophylactic/Diagnostic
Chemotherapy or other biologic agents/complex drugs
3 methods of administration:
Injection
IV Push
Infusion
Initial and subsequent codes – only 1 “initial” code
Start/Stop times must be clearly documented
Methods of Administration - Injection
CPT code 96372 [Therapeutic, prophylactic, or diagnostic INJECTION (specify substance or drug); subcutaneous or intramuscular]
96372 is NOT used for the administration of vaccines/toxoids, and does NOT include injections for allergen immunotherapy
Hospitals may report injection codes when the physician is not present, but physicians do not report them when given without physician supervision.
Injection codes may be used to report non-antineoplastic hormonal therapy
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Methods of Administration – IV Push
CPT code 96374 [IV push, single or initial substance/drug] is to be used when the IV push is the primary service
CPT add-on code 96375 [each additional sequential IV push of a NEW substance/drug] may be reported in conjunction with a primary code to identify an IV push of a new drug when provided as a secondary service after a different initial service is administered through the same IV access
CPT code 96376 [each additional sequential IV push of the SAME drug provided in a facility (add-on code)] is used only when the same drug is administered twice in one encounter, but not within 30 minutes of each other.
All of these IV push codes are reported for facilities only, and may be used for infusions lasting 15 minutes or less (check with your
payors).
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Methods of Administration - Infusion
Coded as “initial hour” and “additional hour” codes
In drug administration terms, “one hour” means any
infusion lasting between 16 and 90 minutes.
Only when an infusion lasts longer than 90 minutes
can you code the “additional hour” code.
“Each additional hour” means increments greater
than 30 minutes over the initial hour.
Do not include time spent keeping veins open.
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Drug Administration Timing
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Single infusion
lasting…
Can be coded … (assuming
documentation is complete)
15 minutes or less IV push
16 - 90 minutes Initial hour
91 - 150 minutes Initial hour + 1 additional hour
151 – 210 minutes Initial hour + 2 additional hours
211 – 270 minutes Initial hour + 3 additional hours
…and so on…
Determining the “Initial” Service
The AMA has created different codes for “initial” and
“subsequent” administrations; coding guidelines state that
there should be only one “initial” code per encounter
unless two separate access sites are required.
Although the rules vary depending on the setting in which
the service is provided, the actual chronological order of
administration is not important for coding. The “initial”
code is not necessarily the FIRST service provided!
In the physician practice, the “initial” service is the
primary reason for the visit.
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“Initial” Service for Hospital Outpatients
In the outpatient facility setting, there is a hierarchy to determine the initial service:
Chemotherapy Infusions
Chemotherapy IV Pushes
Chemotherapy Injections
Therapeutic / Prophylactic / Diagnostic Infusions
Therapeutic / Prophylactic / Diagnostic IV Pushes
Therapeutic / Prophylactic / Diagnostic Injections
Hydration
The highest ranking service provided is considered the “initial” service.
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Concurrent or Sequential Administrations
Order of administration is irrelevant
Administrations of DIFFERENT medications (in separate IV
bags) via one IV line at the same time = concurrent
Report only ONCE per encounter
Add-on code
Back-to-back administrations in the same IV line of
DIFFERENT medications = Sequential
Report only ONCE per sequential infusion of same
infusate mix
Up to one hour
Add-on code
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Hydration 16
CPT Code CPT Description Notes
96360 IV infusion, hydration;
initial, 31 minutes to 1
hour
Do NOT report if performed as
concurrent infusion service; do NOT
report hydration infusion of 30 minutes
or less
Use for infusions of 31-90 minutes
96361 IV infusion, hydration;
each additional hour
(add-on code)
Report for intervals of greater than 30
minutes beyond 1 hour increments; also
report for secondary or subsequent
service after a different initial service
through same IV access
Hydration
Used for pre-packaged fluids and electrolytes
These codes are NOT used for infusion of drugs or
other substances
These codes are NOT to be reported by the physician
in the facility setting
Do NOT report hydration infusions of 30 minutes or
less
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Therapeutic/Prophylactic/Diagnostic
Codes used for the administration of drugs and
other substances (other than hydration)
These codes are NOT to be used for chemotherapy
or other highly complex drugs/biologicals
When fluids are used to administer the drug(s), the
fluid administration is incidental hydration and is
NOT separately reportable
These codes are NOT to be reported by the
physician in the facility setting
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Therapeutic/Prophylactic/Diagnostic
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CPT Code CPT Description Notes
96365 Intravenous infusion, for therapy,
prophylaxis, or diagnosis
(specify substance or drug);
initial, up to 1 hour
Report for IV infusions of 16 - 90 minutes
96366 Intravenous infusion, for therapy,
prophylaxis, or diagnosis
(specify substance or drug); each
additional hour (add-on code)
Report for intervals of greater than 30 minutes
beyond 1 hour increments; also report for
additional hours of secondary or subsequent
service after a different initial service through
same IV access
96367 Intravenous infusion, for therapy,
prophylaxis, or diagnosis
(specify substance or drug);
additional sequential infusion, up
to 1 hour (add-on code)
Report in conjunction with 96365, 96374, 96409,
96413 if provided as secondary service after a
different initial service is administered through the
same IV access
Report only ONCE per sequential infusion of same
infusate mix
Chemotherapy or other biologic
agents/complex drugs
“Chemotherapy” includes other highly complex drugs or biologic agents such as:
non-radionuclide anti-neoplastic drugs
anti-neoplastic agents provided for treatment of non-cancer diagnoses
certain monoclonal antibody agents
other biologic response modifiers
These codes are not to be used by physicians in the facility setting.
Separate codes should be reported for each method of administration when chemotherapy is administered by different techniques
Medications administered independently as supportive management of chemotherapy should be separately reported using 96360, 96361, 96365, 96379 as appropriate.
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Chemotherapy Injections/IV Push Codes 21
CPT Code CPT Description Notes
96401 Chemotherapy administration,
subcutaneous or intramuscular; non-
hormonal anti-neoplastic
96402 Chemotherapy administration,
subcutaneous or intramuscular;
hormonal anti-neoplastic
96409 Chemotherapy administration; IV Push,
single or initial substance/drug
96411 Chemotherapy administration; IV push,
each additional substance/drug (add-
on code)
Report with 96409 or 96413
Chemotherapy Infusion Codes 22
CPT Code CPT Description Notes
96413 Chemotherapy administration,
infusion; up to 1 hour, single or
initial substance/drug
Report for infusions of 16 – 90 minutes
Report 96361 to identify hydration as a
secondary service through the same IV access
Report 96366, 96367, 96375 to identify
therapeutic infusion/injection as secondary
service through same IV access
96415 Chemotherapy administration,
infusion; each additional hour
(add-on code)
Report in conjunction with 96413
Report for infusion intervals of greater than
30 minutes beyond 1 hour increments
96417 Chemotherapy administration,
infusion; each additional
sequential infusion (different
substance/drug) up to 1 hour
(add-on code)
Report in conjunction with 96413
Report only once per sequential infusion
Report 96415 for additional hour(s) of
sequential infusion
Example #1
Patient presents to a hospital outpatient department and
receives an antibiotic infusion of 14 minutes, fluids for
hydration infused over 28 minutes, and a chemotherapy
injection of a non-hormonal anti-neoplastic. What are
the correct codes for this drug administration visit?
14 minute antibiotic infusion = IV push; hydration less
than 30 minutes is not reportable. Only one initial code
is allowed; according to the hierarchy, chemo injections
supersede therapeutic IV pushes. Thus, the chemo
injection is the initial code (96401) and the therapeutic
antibiotic IV push is the sequential code (96375)
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Example #2
Patient presents to a hospital outpatient department and receives an IV infusion of “Drug A” lasting 98 minutes, followed by an infusion of “Drug B” lasting 120 minutes. What are the correct codes for this drug administration visit?
For the infusion of Drug A, code 96365, Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to one hour, is reported for the first hour of infusion. Add-on code 96366, Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure), is reported for the additional 38 minutes beyond the one hour increment of the initial infusion interval.
The infusion of Drug B is reported using code 96367, Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion, up to 1 hour (List separately in addition to code for primary procedure), because it is “sequential” to infusion of Drug A. Code 96366 is reported for the second hour of infusion of drug B.
CPT code 96366 is an add-on code used when a drug is infused for more than one hour and 30 minutes and is also used for additional hours of infusion of sequentially infused drugs. Each new
infusion starts a new time cycle.
Source: CPT Assistant September 2007, Volume 17, Issue 9, pages 3-4
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Blood Administration
Only ONE blood administration code may be
charged per encounter regardless of the number of
units transfused
CPT 34630 – Transfusion, blood or blood
components
Blood products are also chargeable
Blood transfusions are NOT timed codes, although
start/stop times should be documented in the record
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CAATs for Coding Audits
Look for more than one “initial” code per encounter 96360 - IV infusion, hydration; initial, 31 minutes to 1 hour
96365 - Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour
96409 - Chemotherapy administration; IV Push, single or initial substance/drug
96413 - Chemotherapy administration, infusion; up to 1 hour, single or initial substance/drug
Add-on code without primary code (add-on codes are 96361, 96366, 96367, 96368, 96411, 96415, 96417)
Administrations with no medication charge, or vice versa
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More CAATs for Coding Audits
Multiple blood transfusions per encounter (CPT 36430)
Blood administration (CPT 36430) with no blood product(s) (P0000-P9999 series HCPCS codes) charged
Blood administration (CPT 36430) with a revenue code other than 391
CPT 96523 (Irrigation of implanted venous access device for drug delivery systems) billed with any other service
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Questions on Infusion Coding? 28
Other Audit Ideas for Infusion
Centers 29
Operational Audit Ideas
Pharmacy controls, including:
• Dual signatures where applicable
• Inventory controls
• Charges – verify J code units vs. administrations
• 340B compliance, where applicable
Patient Access controls, including:
• Compliance with internal policies
• HIPAA compliance
• Cash controls if co-pays are collected
Patient Safety controls, including:
• Incident reporting
• Physical security
• Consent forms signed
• Orders present and signed
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Other Audit Ideas
Charge capture process review
Charge reconciliation process review / compliance with internal policy (where applicable)
Look for evidence of copy/paste in electronic records
Compliance with medical records retention & storage policies and release of information processes
Vendor contract compliance
Physician contract compliance (where applicable)
Review nursing license/competency compliance
Validate use of individual passwords
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Amy_Smith@bshsi.org
(757) 635-0611
Questions / Comments? 32
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Save the Date
August 30 - September 2, 2015
34th Annual Conference
Portland, Oregon