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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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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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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



(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



(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


96401 Chemotherapy administration,

subcutaneous or intramuscular; non-

hormonal anti-neoplastic


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



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


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


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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[email protected]

(757) 635-0611

Questions / Comments? 32

mailto:[email protected]



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Save the Date

August 30 - September 2, 2015

34th Annual Conference

Portland, Oregon

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