Injections and Infusions

by  Jessica Franzese, CPC CPMA
Oct 14th, 2016 - Reviewed/Updated Aug 17th

Injection and infusion codes can be tricky. In this auditing tip, we'll break them down and help to make them a little easier to understand. Let's start first with the basics. Injections and infusion codes can be found in the medicine section of the CPT® book, codes 96360-96549. They are broken down into three categories. The first is hydration, then therapeutic, prophylactic and diagnostic, and lastly chemotherapy and other highly complex drugs or biological agents.

Injections deliver a substance/drug either in one immediate dose (subcutaneous/intramuscular injections) or over a short period of time (up to 15 minutes) as an intravenous or intra-arterial push. Infusions are a controlled delivery of a substance/drug over an extended period of time (16 minutes or more). Only one "initial" service should be reported, unless protocol requires that a second IV site must be used. For physician reporting, the primary reason for the encounter drives which code should be the initial code, not the order in which the injections/infusions are administered. For facility coding there is a specific hierarchy. Chemotherapy services are at the top, followed by therapeutic/prophylactic/diagnostic services and then hydration services. Likewise infusions supersede pushes which supersede injections.

When performed with an injection or infusion service, the following are included 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

Sequential infusions are infusions or injections of a new substance/drug that follow the initial service. Concurrent infusions are infusions of a new substance/drug that runs at the same time as another substance or drug. These substances/drugs must be running from two separate bags/syringes through one access. Only one concurrent infusion service can be reported per day. Concurrent infusions are not time based.

Hydration codes (96360-96361) report IV infusions that consist of pre-packaged fluid and electrolytes (examples: normal saline, lactated ringers). These are time based codes and a minimum of 31 minutes of hydration is required in order to report the service. Hydration codes cannot be separately reported when the fluids are being run concurrently to therapeutic or chemotherapy infusions. They are also not separately reportable when used to "keep open" an IV line.

Therapeutic, Prophylactic and Diagnostic Injection and Infusion codes (96365-96379) are used to report the injection and/or infusion of non-chemotherapy substances/drugs.

Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration codes (96401-96549) are injections and/or IV infusions of non- radionuclide anti-neoplastic drugs and substances or substances such as monoclonal antibody agents or other biologic response modifiers. Because the incidence of severe adverse reactions is much higher with these drugs, more thorough monitoring is required during their administration.

Now that we have the basics, let's apply them to a few real life situations. We first need to ask ourselves, what type of substance/drug did the patient receive? Next we need to know how (which route) the substance/drug was given? And finally, how long did the administration of the substance/drug take?

Scenario #1:

The patient now has crystal confirmed gout with

tophaceous involvement. We will treat the current flare with Kenalog 60mg IM injection followed by a prednisone taper. IM Kenalog 60mg given in Left Glute - 10:15am - Patient tolerated with no difficulties.

Our questions:

What did the patient receive?

-non-chemo therapeutic (Kenalog)

How did the patient receive it?

-Intramuscular injection

How long did the administration take?

-One immediate dose

Our code:

96372 [Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular]

Scenario #2:

Diagnosis: Rheumatoid Arthritis Infusion

Type: Remicade Dose: 700mg Site: L wrist

Gauge: 24 G auto gauge insyte Length: ¾ inch Attempts: 1 Needle in time: 0820 Infusion time started 0825 20cc flushed end time 1025 Needle out time: 1030 Was any drug wasted? NO Premedicate with Acetaminophen 500mg 1 or 2 PO, Claritin 10 mg 1 PO IV site without swelling, pain or discoloration: YES

Patient denies infection and not on antibiotics. Pt stated she took Tyl./Clar. as premeds. IV access established. Remicade 700mg is 10.4mg/kg given IV as ordered for Dx code 714.0. Patient tolerated infusion well without difficulties. 40 mg Solumedrol given slow IVP (4 minutes) as ordered post infusion. Patient tolerated IVP well without difficulties. IV catheter dc'd intact.

Our questions:

What did the patient receive?

-Chemotherapy (high risk) Remicade; non-chemo therapeutic - Solumedrol

How did the patient receive them?

-IV infusion; IV push

How long did the administration take?

-2 hours; 4 minutes

Our codes:

96413 [Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug] 96415 [Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure

96375 [Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure)]

Scenario #3

Patient presents with dehydration and is given IV hydration with a dose of Zofran.

Patient receives an IV push of Zofran and IV hydration. Zofran: IV push (2 min)

Normal Saline @125 cc/hour: start time 1405, end time 1615

Our questions:

What did the patient receive?

-Hydration - NS; non-chemo therapeutic - Zofran

How did the patient receive them?

-IV push; IV infusion

How long did the administration take?

-2 minutes; 2 hours and 10 minutes

Our codes:

96360 [Intravenous infusion, hydration; initial, 31 minutes to 1 hour]

96361 [Intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure)]

96375 [[Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure)]

When working with injection and infusion codes, always read the coding guidelines/section notes thoroughly. When selecting a code, be sure to use both the code descriptor and parenthetical notes in making your selection. And finally, it is important also, to refer to your local MAC carrier for any specific guidance and/or LCDs.