Injection and Infusion Coding Offers High Stakes: Outpatient Coders Must Play Their Cards Right

By Charles Flewelling, Jr., RHIT

With the consistently rising value of highly skilled outpatient coders, numerous HIM departments are moving to a staffing model that employs coding professionals who are well versed in coding both inpatient and outpatient encounters. Coders in the profession today should possess a mastery of the complex inpatient coding rules as well as the very specific—and equally complex—outpatient coding rules.

One of the most demanding aspects of outpatient coding is the selection of injection and infusion (I&I) codes. This set of Current Procedural Terminology (CPT) codes, 96360 through 96549, is utilized to capture I&I administered in the emergency department (ED). I&I coding is also appropriate in observation patients who have been transferred from the ED. Rarely, if ever, are I&I codes appropriate if the patient is transferred from the ED to inpatient status.

When approaching I&I coding, it can be helpful to think of the code assignments in terms of playing cards or a hand of poker. It’s important to determine not only what you have in your hand, but also which cards trump the others. Coders must have a firm grip on the definitions of several terms in order to achieve success with I&I codes—just as a poker player needs to know all their options when trying get their best hand possible—as well as which I&I procedures will outrank others—just as an ace trumps a jack, so too does chemotherapy trump the other procedures. This article gives an overview of the information essential to successful I&I coding.

Hierarchy of I&I Codes

  1. Chemotherapy (96401)
  2. Infusions (96365)
  3. Injections (96374)
  4. Hydration (96360)

Coders Must Master Many Term Definitions

For success with I&I codes, coders must have a firm grasp on the definitions of the following terms:

  • Infusion: Administration of diagnostic, prophylactic, or therapeutic intravenous (IV) fluids and/or drugs given over a period of time. (Examples: Banana bags, heparin, nitroglycerin, antiemetics, antibiotics, etc.)
  • Injection: The act of forcing a liquid into the body by means of a needle and syringe. Injections are designated according to the anatomic site involved; the most common are intra-arterial, intradermal, intramuscular, intravenous, and subcutaneous. Injection delivers a dosage in one “shot” rather than over a period of time.
    • IV Push (IVP): (a) An IV administration of a therapeutic, prophylactic, or diagnostic drug; (b) An infusion that runs for 15 minutes or less; (c) Any infusion without documentation of a stop/continuing time.
    • IV Piggyback (IVPB): A method to administer medication through an existing IV tube inserted into a patient’s vein, hence the term “piggyback.” The medication in an IV piggyback is usually mixed in a small amount of compatible fluid, such as normal saline.
    • Intramuscular (IM) Injection: An injection of a therapeutic, prophylactic, or diagnostic drug into the substance of a muscle, usually the muscle of the upper arm, thigh, or buttock. Intramuscular injections are given when the substance needs to be absorbed quickly.
  • Hydration: Typically an administration of prepackaged fluids and/or electrolytes without drugs. Examples include normal saline (NS), sodium chloride (NaCl), dextrose 5 percent in water (D5W), dextrose in ½ normal saline (D5 ½ saline), dextrose in ½ normal saline plus potassium (D5 ½ NS+K).

The coder must also thoroughly understand the guidelines provided by the American Medical Association (AMA) in the use of these codes. With a complete working knowledge of these areas, the coding professional can apply the correct CPT codes.

In addition to the definitions listed above, other considerations to make when selecting the appropriate I&I code include payer-specific policies, vast instructional notes, and the hierarchy system laid out in the AMA’s Current Procedural Terminology reference book. Understanding the hierarchy of these procedures can be challenging for novice and experienced outpatient coders alike. According to the CPT guidelines, “chemotherapy services are primary to therapeutic, prophylactic, or diagnostic services which are primary to hydration services. Infusions are primary to pushes, which are primary to injections.”

Whenever chemotherapy is performed, it will trump all other services. But since infusions, injections, and hydrations are most common in the ED setting, this article will continue the I&I discussion without a focus on chemotherapy.

Typically, only one initial service code will be captured—even when multiple drugs are being administered. The exception is when there is more than one IV access site or when there are multiple encounters during the same date of service.

The coder will need to determine three things initially:

  1. What did the patient receive?
  2. How was it given?
  3. How long did it take?

An initial service of an infusion will trump injections and/or hydration. If the initial service is determined to be an injection, then it will outrank hydration, but not infusion.

To determine the initial code, there are a few things the coder needs to consider:

  1. Was there an infusion of 16 minutes or more? If so, infusion (96365) should be coded, as it outranks both injection and hydration.
  2. If there was no infusion, was there an injection? If so, injection (96374) should be coded, as it outranks hydration.
  3. If there were no infusions or injections, was there a hydration of longer than 31 minutes? If so, then hydration (96360) should be coded.

Subsequent or sequential IVPs are then coded as appropriate. See the sidebar below for more information on this process.

Hierarchy for Subsequent or Sequential IVPs

Infusion

IV Push

Hydration

96365 - Initial infusion up to 1 hour

96366 - Each additional hour

96367 - Sequential infusion up to 1 hour (use 96366 for additional hours of sequential infusion)

96368 - Concurrent infusion (report only one per encounter)

96375 - IV push, each push of a different drug

96376 - Each IV push of the same drug at intervals > than 30 minutes

96361 - Hydration (do not charge at the same time of infusion); must be 31 minutes or longer

96372 - IM/SubQ Injection

90471 - IM/SubQ Vaccine

96374 - Initial push or infusion less than 16 minutes

96375 - IV push, each push of different drug

96376 - Each IV push of same drug at intervals >30 minutes

96361 - Each hour of hydration; must be 31 minutes or longer

96372 - IM/SubQ Injection

90471- IM/SubQ Vaccine

96360 - Initial hydration up to 1 hour; must be at least 31 minutes

96361 - Hydration each additional hour; must be 31 minutes or longer

96372 - IM/SubQ Injection

90471- IM/SubQ Vaccine

*** Note: In any case with an IVP injection, infusion, or hydration along with an IM or SubQ injection, the IM or SubQ injection will require modifier -XU for unusual, overlapping services (96372-XU)

Coding Subsequent or Sequential IVPs

Courtney Johnson, RN, BSN, RHIA, CCS, coding specialist at Baylor University Medical Center, gave the following steps for counting infusion times in a presentation during the August 2012 Coder Summit conference call held quarterly for all Baylor coders, auditors, HIM managers, and CDI staff.

Once the initial service code is captured, subsequent or sequential IVPs are coded as appropriate. The sidebar above illustrates how the hierarchical process for coding subsequent or sequential IVDPs falls into place. To begin, select the most appropriate column based on the chart documentation and the hierarchical principle. Then, once the initial service code is chosen, make all further CPT code choices from within the column with that code at the top.

As the coder picks the appropriate column and then follows it down for the appropriate codes, they must also remember that it is critical to look at the chronological order of the infusions in order to determine the correct codes.

It is just as important to pay close attention to the times of the infusions. In order to accurately code infusions, not only must there be a start time (usually documented), but there must be a stop time (problematic in most EDs).

An infusion or hydration that runs alone with no IVPs interrupting will be counted by minutes from the start time to the documented stop time.

If the patient is transferred or admitted to another patient status, count from the start time to the time that the admit order is written. Some facilities consider admit time as the time of the admit order. Others may count the time from the actual transfer of the patient.

If hydration was interrupted by either an IVP or IVBP, you must count only the time the hydration ran alone. (The time rule still applies; it must run for 31 minutes or more alone to count.)

For each IVP that is given during hydration, subtract 15 minutes from the normal saline time, unless multiple IVPs are given within 15 minutes of each other.

Infusion and Injection Case Example Scenario

With these principles and guidelines in mind, consider the following common occurrence in the ED. A patient is admitted complaining of acute abdominal pain. An IV is set up to infuse normal saline, Zofran for the nausea, and morphine for the pain. Coders for the ED see this scenario, or variations of this scenario, numerous times a day. What are the codes that should be assigned?

Scenario #1

Documentation from the ED Physician Notes:

Administered Medications:

  • 19:21 Drug: Zofran 4 mg Route: IVP; Site: left antecubital
  • 20:54 Follow up: Response: No adverse reaction; Nausea is decreased
  • 19:21 Drug: morphine 4 mg Route: IVP; Site: left antecubital
  • 20:54 Follow up: Response: No adverse reaction; Pain is decreased
  • 19:21 Drug: NS 0.9 percent 1,000 ml Route: IV; Rate: bolus; Site: left antecubital
  • 20:54 Follow up: [no stop time documented]

Documentation from the MAR

ED Meds

Day 1

Day 2

Zofran

4 mg IVP

19:21

4 mg

Morphine

4 mg IVP

19:21

4 mg

NS

1,000 ml IV

19:21

bolus

Codes assigned are 96374 and 96375. In this instance, start times are given for all infusions but none have stop times. Each infusion is counted as 15 minutes. When these times are subtracted from the normal saline (NS) infusion time (15 minutes), there is no NS time to code. Many institutions give away numerous infusions due to the lack of appropriate documentation. There are also numerous facilities that have specific staff dedicated to the job of scanning the ED to make sure that ED documentation is complete with both start and stop times.


Scenario #2

Documentation from the ED Physician Notes:

Administered Medications:

  • 19:21 Drug: Zofran 4 mg Route: IVP; Site: left antecubital
  • 20:54 Follow up: Response: No adverse reaction; Nausea is decreased
  • 19:21 Drug: morphine 4 mg Route: IVP; Site: left antecubital
  • 20:54 Follow up: Response: No adverse reaction; Pain is decreased
  • 19:21 Drug: NS 0.9 percent 1,000 ml Route: IV; Rate: bolus; Site: left antecubital
  • 20:54 Follow up: IV status: Completed infusion. IV intake: 1,000ml

Documentation from the MAR

ED Meds

Day 1

Day 2

Zofran

4 mg IVP

19:21

4 mg

Morphine

4 mg IVP

19:21

4 mg

NS

1,000 ml IV

19:21

bolus

20:54

complete

Codes assigned are 96374, 96375, and 96361. The NS can now be captured because it has a documented stop time. Since there are still no documented stop times on the Zofran and morphine, only assign 15 minutes for each. NOTE: some facilities will apply only one 15-minute unit to multiple meds if they are given at the same time, considering it as a single infusion. Some will allot a 15-minute unit for each different medicine given at the same time. Be sure to check with your facility on whether this is a multiple allotment or just a single allotment of 15 minutes. This could very well affect whether to code 96361 for a subsequent hour of NS infusion.


Scenario #3

Documentation from the ED Physician Notes:

Administered Medications:

  • 19:21 Drug: Zofran 4 mg Route: IVP; Site: left antecubital
  • 20:54 Follow up: IV status: Completed infusion Response: No adverse reaction; Nausea is decreased
  • 19:21 Drug: morphine 4 mg Route: IVP; Site: left antecubital
  • 20:20 Follow up: Response: No adverse reaction; Pain is decreased
  • 19:21 Drug: NS 0.9 percent 1,000 ml Route: IV; Rate: bolus; Site: left antecubital
  • 20:54 Follow up: IV status: Completed infusion

Documentation from the MAR

ED Meds

Day 1

Day 2

Zofran

4 mg IVP

19:21

4 mg

20:54

complete

Morphine

4 mg IVP

19:21

4 mg

20:20

NS

1,000 ml IV

19:21

bolus

20:54

complete

Codes assigned would be 96365 and 96375. Normal saline (NS) will not be coded due to the Zofran infusing during the entire NS time. The total time for the infusion of Zofran was 93 minutes, well over the initial 31 minutes to qualify to be coded 96365.

The three illustrated scenarios above take this basic premise and apply the guidelines discussed in this article, assigning the appropriate CPT code for the infusion. The following two scenarios, change the documentation slightly to illustrate other important factors to consider for I&I coding.

Scenario #4

Documentation from the ED Physician Notes:

Administered Medications

19:21 Drug: Zofran 4 mg Route: IVP; once over two minutes; Site: left antecubital
19:23 Follow up: Response: No adverse reaction; Nausea is decreased

19:21 Drug: morphine 4 mg Route: IVP; once over two minutes; Site: left antecubital
20:54 Follow up: Response: No adverse reaction; Pain is decreased

19:21 Drug: NS 0.9 percent 1,000 ml Route: IV; Rate: bolus; Site: left antecubital
20:54 Follow up:

Documentation from the MAR:

ED Meds Day 1     Day 2
Zofran
4 mg IVP once: over two minutes
19:21
4 mg
     
Morphine
4 mg IVP once; over two minutes
20:21
4 mg
     
NS
1,000 ml IV
1921
75 ml/hr
20.54
complete
   

Codes assigned would be 96374, 96375, & 96361. The Zofran and morphine each infused for only two minutes. Add those together and subtract the four minutes from the total NS infusion time (93 minutes), which results in 89 codeable minutes, or 1 hour and 29 minutes. A minimum of 31 additional minutes would be needed to code an additional 96361 code. Here the coder can code 96361 only one time. If the NS stop time was at 21:03, for instance, that would be 1 hour and 38 minutes and would justify two 96361 codes.


Scenario #5

Documentation from the ED Physician Notes:

Administered Medications:

13:29 Drug: Zofran 4 mg; Route: IVP; once over two minutes; Site: left antecubital
13:59 Follow up: Response: No adverse reaction; Nausea is decreased

13:29 Drug: morphine 4 mg Route: IVP; once over two minutes; Site: left antecubital
20:54 Follow up: Response: No adverse reaction

14:31 Drug: Zofran 4 mg; Route: IVP; once over two minutes; Site: left antecubital
14:59 Follow up: Response: No adverse reaction; Nausea is decreased

17:45 Drug: Zofran 4 mg Route: IVP; Site: right antecubital
18:14 Follow up: Response: No adverse reaction; pain is decreased

17:45 Drug: Dilaudid 1 mg Route: IVP; Site: right antecubital
18:13 Follow up: Pain 5/10 adult

13:29 Drug: NS 0.9 percent 1,000 ml Route: IV; Rate: bolus; Site: left antecubital
15:30 Follow up: IV status: Completed infusion

Documentation from the MAR:

ED Meds Day 1     Day 2
Zofran
4 mg IVP once: over two minutes
17:45
4 mg
     
Zofran
4 mg IVP
14:31
4 mg
     
Zofran
4 mg IVP
13:29
4 mg
     
Morphine
4 mg IVP once; over 2 minutes
13:29
4 mg
     
Dilaudid
1 mg IVP once
17:45
1 mg
     
NS
1,000 ml IV
13:29
1,000 ml IV
15:30
Complete
   

Codes assigned would be 96374, 96375, 96376, 96361, 96361, 96374-XS, and 96375-XS. The importance of knowing the chronological order that meds have been infused cannot be overemphasized. The location of the infusion site is of equal importance. In this case, NS, Zofran, and morphine were initially given at 13:29. A second Zofran was given IVP at 14:31. This second infusion of Zofran occurred over 31 minutes from the initial infusion with the resulting code of 96376. Then, at 17:45, morphine and dilaudid are infused. But, notice that these were started in the right antecubital whereas the previous infusions were in the left antecubital. Subsequent infusions at a different site than the first infusion will justify a second initial infusion code, 96374. The modifier -XS is added to the CPT code to make clear that this is a second site.

References

AHIMA. CPT Coding for Injections and Infusions. Audio Seminar, May 8, 2012.

American Medical Association. CPT Professional Edition. Chicago, IL: AMA, 2015.

Endicott, Melanie. “Taking the Sting out of Injection and Infusion Coding.” Journal of AHIMA 83, no. 11 (November 2012): 74-76. http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_049797.hcsp?dDocName=bok1_049797.

Johnson, Courtney. “Injection and Infusion Coding.” Presentation during Baylor Scott and White Health Coder Summit conference call, August 2012.

Garrett, Joyce. “Basic Coding for Infusions and Injections.” Internal Presentation to Franciscan Health Services, 2008.

Rubinowitz, Andrea Clark. "Infusion Confusion What's Your Solution!! 2008 Jokers' Wild Edition." Presentation at the Association for Healthcare Internal Auditors 2008 Annual Conference. https://www.resourcenter.net/images/AHIA/Files/2008/AnnMtg/Handouts/TrackF6.pdf

Charles Flewelling, Jr. (Charles.Flewelling@baylorhealth.edu) is a corporate remote coding auditor at Baylor Scott and White Health, based in Dallas, TX.


Article citation:
Flewelling, Charles. "Injection and Infusion Coding Offers High Stakes: Outpatient Coders Must Play Their Cards Right" Journal of AHIMA 86, no.6 (June 2015): extended online version.