Updated on: June 22, 2012

Be Prepared and Proactive for RAC with Clear and Precise Documentation for Infusion Therapy

By Patricia A. Shell, CPC, CPC-H, CIRCC, RCC
Original story posted on: February 29, 2012

p-shellDocumentation, medical necessity, and code assignment are more important than ever. Previously, Recovery Audit Contractors (RACs) identified multiple initial chemotherapy administration and non-chemotherapy injections and infusions codes on the same day without an appropriate modifier.

The four codes below were at the top of the problem list:

 

96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug
96365 Intravenous infusion, for therapy, prophylaxis or diagnosis (specify substance or drug); initial, up to 1 hour
90769 Subcutaneous infusion for therapy or prophylaxis (The American Medical Association deleted this code on January 1, 2009 and replaced it with the following code.)
96369 Subcutaneous infusion for therapy or prophylaxis (specify substance or drug): initial, up to 1 hour, including pump set-up and establishment of subcutaneous infusion site(s)

 

Under some circumstances, two initial infusions may be assigned when there is "supporting documentation" for the assignment of modifier 59 (distinct procedural service). Due to the possibility of assigning two initial CPT® procedure codes with modifier 59, CMS recommends that providers pay close attention to the instructions for what constitutes an "initial" service code and when to use modifier 59.

 

Infusions, Hydration Infusions and Injections: 2012 Coding Guidelines

 

The 2012 CPT® code book provides instructions that physicians use for code assignments and defines the coding hierarchy to be used hospitals as follows.

 

Physicians assign codes based upon their knowledge of clinical condition(s) and treatment(s). Hospitals assign based upon the coding hierarchy. Specifically, regardless of the order of the infusion, chemotherapy drug administration is always primary over non-chemotherapy drug administration, which is always primary over hydration. Infusions are primary to pushes, which are primary to injections.

 

Facilities must follow this hierarchy, which supersedes the parenthetical instructions for add-on codes that are included in the CPT code book. The instructions suggest that an add-on code of a higher hierarchical position may be reported in conjunction with a base code of a lower position.

 

Most Frequent Documentation Problems

 

As with other RAC reviews, problems arise with insufficient or incomplete documentation. In the area of infusion therapy, several areas are affected. Problem areas are listed below.

 

Intravenous Infusion Hydration Therapy

 

  • The physician order for hydration fluids administered during the encounter for drug administration, chemotherapy or blood administration is missing.
  • No distinction is made between hydration administration that is the standard of care, facility protocol and/or drug protocol for administration of hydrating fluids, pre- or post-medications.
  • Documentation is insufficient and does not support medical necessity of pre-hydration, simultaneous or subsequent hydration.

 

Infusion Services

 

  • Documentation does not confirm administration through a separate access site.
  • Poor documentation for the line flush between drugs makes it impossible to determine whether compatible substances or drugs were administered concurrently or sequentially.
  • The inadequate documentation of the access site and/or each drug's start and stop times makes it impossible to determine whether compatible substances or drugs were mixed in the same bag or syringe or administered separately.
  • Start and/or stop times for each substance infused are often times missing.
  • The documentation of infusion services was started in the field by emergency medical services (EMS) and continued in the emergency department (ED).
  • Documentation of infusion services that were initiated in the ED continued upon admission to outpatient observation status.
  • Working with vendors on electronic health records (EHR) to implement revisions to electronic forms in order to comply with changing documentation requirements was difficult.

 



 

Recommended Documentation Plan

 

  • Develop and/or revise documentation forms that conform to the coding guidelines for injections, intravenous (IV) pushes, and IV infusions.
  • Clinical personnel should focus on patient care and ensure accurate and complete documentation of the encounter.
  • Pharmacist should communicate classification of drug, fluid or substance to aide in the correct application of procedure codes.

 

In addition to the above, health information management (HIM) coding professionals should ensure accurate coding through review of documentation in patient record to:

 

  • Apply official coding guidelines.
  • Assign CPT®/HCPCS infusion codes.
  • Apply modifiers (if indicated).
  • Generate charges for infusion-administration services.
  • Review accuracy of drug codes and associated billing units.

 

About the Author

 

Patricia A. Shell is a senior healthcare consultant with Medical Learning, Inc., a Panacea Healthcare Solutions company, St. Paul, MN.

 

Contact the Author

 

pshell@medlearn.com

 

To comment on this article please go to editor@racmonitor.com

 

CPT® is a registered trademark of the American Medical Association

 

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