Resolved Coding Infusions Injections & Hydrotherapy

Lori · Aug 24, 2023

Infusion Therapy

Bolus – A ‘bolus’ is defined as a single, large dose of medication usually injected into a blood vessel over a short period of time and is billed as
an intravenous (IV) push per CPT guidelines.

“Banana Bag” or rally pack
Considered therapeutic administration – 96365 category
Bag of IV fluids containing vitamins and minerals

If the drug is considered self-administrable, the injection is not covered

For purposes of facility coding, an infusion is required to be more than 15 minutes for safe and effective administration. Hydration therapy is always secondary to infusion/injection therapy.

For example, if the initial administration infuses for 20 to 30 minutes the provider would bill one unit because the CPT® (Current Procedural Terminology) /HCPCS (Healthcare Common Procedure Coding System) code states 'initial up to or first hour'. If an additional drug is administered and infused for 20 minutes no additional units would be billed, as the one-hour increment has not been exceeded. The medication administration record and/or the nursing documentation should coincide with the billing based on the time of initiation, time of completion, and discharge from the outpatient facility.

Intravenous (IV) infusions are billed based on the CPT®/HCPCS description of the service rendered. A provider may bill for the total time of the infusion using the appropriate add-on codes (i.e. the CPT®/HCPCS for each additional unit of time) if the times are documented. Providers may not bill separately for items/services that are part of the procedures (e.g., use of local anesthesia, IV start, or preparation of chemotherapy agent).

The appropriate CPT®/HCPCS codes for the IV infusion/administration of drugs should be used with the appropriate number of units. Upon initiation of the infusion, it is expected that the start time be documented as well as the stop time. The nursing documentation and/or medication administration record should indicate this information and be signed by the appropriate clinical staff.

When requested, providers should submit documentation indicating the volume, start and stop times, and infusion rate (s) of any drugs and solutions provided. In the absence of the stop time the provider should be able to calculate the infusion stop time with the volume, start time, and infusion rate.

Injections/IV Push Therapy

An intravenous injection (IV push) is an infusion of 15 minutes or less. If an IV push is administered the following criteria must be met:

•A healthcare professional administering an injection is continuously present to administer and observe the patient
•An infusion is administered lasting 15 minutes or less

Article - Billing and Coding: Infusion, Injection and Hydration Services (A53778)

Use this page to view details for the Local Coverage Article for Billing and Coding: Infusion, Injection and Hydration Services.

www.cms.gov

Lori · Aug 24, 2023

Hydration Therapy

Hydration is defined as the replacement of necessary fluids via an IV infusion which consists of pre-packaged fluid and electrolytes. Some of the solutions utilized in the administration of hydration services are:
Saline solutions,
D5W (dextrose 5% water),
Hypotonic solution,
Ringer Lactate, and
DW ( Distilled water)

Hydration must be medically reasonable and necessary. If documentation supports a clinical condition that warrants hydration, other than one brought about by the requirements of a procedure, the hydration may be separately billable.

• Necessity should be supported within medical documentation
• Routine administration of IV fluids without documentation of supporting signs/symptoms such as dehydration or fluid losses is not supported as medically necessary
• Medical necessity is supported in the evaluation performed by provider Documentation of assessment should describe symptoms warranting hydration, such as:
• Inability to ingest fluids
• Abnormal fluid losses – (i.e. Dehydration)
• Abnormal vital signs
• Abnormal laboratory studies - elevated BUN, creatinine, glucose or lactic acid

• Note: Nausea alone does not implicate fluid volume depletion nor support
the necessity of fluid repletion

The rate of infusion is important in determining hydration therapy
• Typically at least 100 - 125/cc – up to wide open IV flow
• If it ordered below 100/cc, physician documentation must indicate that it ishydration and why a slower rate is ordered
• Patient with Congestive Heart Failure
• Elderly patient in which hydration needs to be administered slowly

“Will hydrate the patient” should not be your only determining statement

When fluids are used solely to administer the drugs, i.e. the fluid is merely the vehicle for the drug administration, the administration of the fluid is considered incidental hydration and not separately billable.

CPT® instructions require the administration of a hydration infusion of more than 30 minutes in order to allow the coding of hydration as an initial service. Hydration of less than 30 minutes is not separately billable. The charges for an administration of 30 minutes or less should be reported with an appropriate revenue code, but without a HCPCS or CPT® code. Hydration therapy of 30 minutes or more should be coded as initial, 31 minutes to one hour, and each additional hour should be listed separately in addition to the code for the primary infusion/injection.

96360 Intravenous infusion, hydration; initial, 31 minutes to 1 hour
96361 Intravenous infusion, hydration; each additional hour (list separately in addition to primary code)

A minimum of 31 minutes of hydration is required to report the service. Hydration provided for less than 30 minutes would not be reportable.

Not used when the purpose of IV fluid is to “keep open” an IV line.

• The sole purpose of the IV fluid administration is to keep the vein open or maintain vascular access, this should not be separately reported.
• Not used when fluid is the vehicle in which the drug is administered
• Not used when used to accommodate a therapeutic IV piggyback through the same IV access as a free-flowing IV to safely infuse the agent
• Not used for routine administration of IV fluids, pre/post operatively while the patient is NPO for example, without documentation supporting signs and/or symptoms including those of dehydration or fluid loss
• Concurrent hydration is not billable via a HCPCS code and not separately payable

Report 96361 for hydration intervals of greater than 30 minutes beyond 1 hour increments
• More than 90 minutes of total infusion time must elapse before the “additional hydration” code may be billed

91-150 minutes 96361 – 1 unit
151-210 minutes 96361 – 2 units

• Report 96361 to identify hydration if provided as a secondary/subsequent service after a different initial service (96360, 96365, 96374, 96409,
96413) is administered through the same IV access
• Remember Emergency Department through Observation is all one encounter, so if hydration began in ED and is the only injection/infusion service, only bill the initial hydration once

Lori · Aug 24, 2023

Frequently Asked Questions

In what order should hospitals bill infusion and injections?

Consistent with the special instructions for facilities in the CPT® manual, infusion should be primary, injections/IV pushes next and hydration therapy last. Infusion>Injection>Hydration).

How many initial services may be billed per day?

Only one initial code is allowed per patient encounter unless two separate IV sites are medically reasonable and necessary (use modifier 59). If the patient returns for a separate and medically reasonable and necessary visit/encounter on the same day, another initial code may be billed for that visit with CPT® modifier 59.

What is the difference between an IV push and an IV infusion?

An IV push is an infusion of 15 minutes or less and requires that the health care professional administering the injection is continuously present to observe the patient.

In order to bill an IV infusion, a delivery of more than 15 minutes is required for safe and effective administration.

When can a sequential infusion be billed?

Following the completion of the first infusion, sequential infusions may be billed for the administration of a different drug or service through the same IV access. There must be a clinical reason that justifies the sequential (rather than concurrent) infusion. Sequential infusions may also be billed only once per sequential infusion of same infusate mix.

There is no concurrent code for either a chemotherapeutic IV infusion or hydration. Can a concurrent infusion be billed?

Any hydration, therapeutic or chemotherapeutic infusion occurring at the same time and through the same IV access as another reportable initial or subsequent infusion is a concurrent infusion. Concurrent administration of hydration is not billable via a HCPCS code and not separately payable. In general, chemotherapeutics are not infused concurrently, however if a concurrent chemotherapy infusion were to occur, the infusion would be coded with the chemotherapeutic unlisted code.

When can hydration be billed?

Documentation must indicate that the hydration service is medically reasonable and necessary. It should not be an integral part of another service such as an operative procedure. The rate of infusion should be included in the documentation. When fluids are used solely to administer drugs or other substances, the process is considered incidental hydration and should not be billed. To code hydration as an initial service, hydration must be a medical necessity and administered for more than 30 minutes. Hydration of 30 minutes or less is not separately billable. The charges for an administration of 30 minutes or less should be reported with an appropriate revenue code but without a HCPCS or CPT® code. Each additional hour of hydration infusion requires an initial service being delivered (hydration or other infusion/injection service).

If a patient is receiving an IV infusion for hydration and the stop time is not documented in the medical record, how should the service be coded?

Infusion times should be documented. Hydration of 30 minutes or less is not separately billable. When requested, providers should submit documentation indicating the volume, start and stop times, and infusion rate (s) of the solution provided. In the absence of the stop time the provider should be able to calculate the infusion stop time with the volume, start time, and infusion rate and code accordingly.

What are the most frequent documentation problems in the area of infusion therapy?

As with other Medicare contractor 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 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

Lori · Aug 24, 2023

Chemotherapy:

Report one initial service CPT code
• Specific drug(s) or biological(s) used
• HCPCS codes
• Dosage
• J code value = units reported
• Unless protocol requires two separate IV sites
• Modifier 76 if simultaneously
• Modifier 59 if different encounter
• Saline, anti-nausea, or non-chemo drugs
• Same day sequentially – report separately
• Medically necessary before or after chemotherapy

HCPCS Level II establishes “Chemotherapy Drugs” as those in the
range of codes J9000-J9999. Infusion of drugs with assigned HCPCS
codes in this range are accepted as appropriately billed using the
chemotherapy administration codes.
• Example of administration of hormonal anti-neoplastic drug
• Degarelix (Firmagon) – classified as an injectable chemotherapy drug
• J9155
• Report with CPT administration code 96402
• Noridian has indicated use of an appropriate chemotherapy administration code for an infusion or IV push of certain drugs (because of documented increased infusion reactions and/or other reasons necessitating increased administration practice expense)
Same day same time – bundled into chemo administration

Noridian published a list of drugs for which the administration of the drugs in their subcutaneous or intramuscular forms should not be billed using a chemotherapy administration code.
• Instead, unless listed in Noridian’s Self-Administered Drugs article,
these should be billed using CPT code 96372.
• Denosumab (Prolia/Xgeva) J0897
• Abatacept (Orencia) J0129
• Pegfilgrastim (Neulasta) J2505 *Note Effective 01/01/2018 providers are instructed to use 96377 for the on-body application injector for Neulasta
Onpro Kit
• See Noridian Local Coverage Article on Chemotherapy Administration (A52991)

Providers may only bill Chemotherapy Administration codes (96401-96549) for the following as these require additional physician or other QHP work and/or clinical staff monitoring above therapeutic drug administration codes (96360-96379):

Parenteral administration of non-radionuclide anti-neoplastic drugs
Administration of anti-neoplastic agents provided for treatment of non-cancer diagnoses (e.g., cyclophosphamide for auto-immune conditions)
Administration of monoclonal antibody agents
Administration of other biologic agents

Providers should not report Chemotherapy Administration codes for:

Administration of anti-anemia drugs
Administration of anti-emetic drugs

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:

What did the patient receive?
How was it given?
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:

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

Lori · Aug 24, 2023

Documentation:

Physicians/QHPs – Report as infusion or injection based on the physician’s/QHP’s knowledge of the clinical condition(s) and treatment(s)
Facilities – Report based on CPT hierarchy rules:
- Chemotherapy services are primary to Therapeutic, Prophylactic and Diagnostic services
- Therapeutic, Prophylactic and Diagnostic services are primary to hydration.
- The order is:
  - Chemotherapy
  - Therapeutic, prophylactic, and diagnostic services
  - Hydration
- Infusions are primary to IV pushes, which are primary to injections. The order is:
  - Infusions
  - IV push
  - Injection

Documentation should support the services reported
• Therapeutic Infusions Hydration
• 1st Hour 16-90 minutes 31-90 minutes
• 2nd Hour 91-150 minutes 91-150 minutes
• 3rd Hour 151-210 minutes 151-210 minutes

Infusion Start / Stop Time
Infusions may be concurrent (i.e., multiple drugs are infused simultaneously through the same line) or sequential (infusion of drugs one after another through the same access site). Selection of the correct CPT code is dependent upon the start and stop time of infusion services. If “stop time” is not documented, only an IV push can be billed. An IV infusion differs from an IV push. An IV push is defined as an infusion lasting 15 minutes or less. Therefore, it is important to use the following guidance:

Infusion services are coded based on the length of the infusion, which is a time-based service.
– 15 minutes or less - Infusions lasting 15 minutes or less would be coded as an IV push
– 16 minutes or more – Infusion codes can be reported after 16 minutes.
The Start and Stop times of each medication administration must be accurately recorded, as this determines the correct CPT code assignment.
The first hour of infusion is weighted heavier than subsequent hours to include preparation time, patient education, and patient assessment prior to and after the infusion.
The time calculations for the length of the infusion should stop when the infusion is discontinued and restart at the time the infusion resumes.

“Initial” service is described as “the service that best describes the key or primary reason for the encounter”
• Order of service delivery does not determine what is “initial” service
• Hierarchy does not apply to Subcutaneous/Intramuscular injections
• Only one per patient encounter UNLESS:
• Two separate IV sites are medically used/necessary
• Patient returns for a separate and medically necessary and reasonable encounter on the same day
• These may be reported with two initial services with a modifier -59 (XE) on the second IV or second encounter

When you bill IV hydration along with IV pushes, always report the IV push as the initial code. According to the CPT hierarchy, the initial
code must be 96374.
• Following that code, 96361 must be assigned for the hydration.

Sequential is when multiple drugs are infused “back to back” or one after the other
• Must be a DIFFERENT drug through the same IV access
• Must be a clinical reason for doing sequential versus concurrent
• 96367 (additional sequential infusion) – report once per drug
• If additional hours of infusion, report 96366

Concurrent is when multiple therapeutic or diagnostic medications (not hydration fluids) are infused simultaneously through separate bags through the same IV line
• Concurrent codes are not to be used for multiple drugs within the same bag
• Typically concurrent is used for “gravity drip” infusion methods
• 96368 (concurrent infusion) - report once per date of service
• If additional hours of infusion, report 96366

Included in the CPT codes – do not bill separately

Local anesthesia
IV start
Access to subcu catheter or port
Flush at the conclusion
Standard tubing
Syringes
Supplies

Infusion time is calculated from the time the administration commences (i.e., the infusion starts dripping) to when it ends (i.e., the infusion stops dripping). Services leading up to the infusion and following the infusion have been included in the infusion code services and are not reported separately.

Health care professional must be continuously present
• Administer the drug
• Observe the patient

Do not report if Infusion of 15 minutes or less.

Do not report injections and infusions given during the course of outpatient surgery and recovery
• Therapeutic IVs and injections given beyond the “normal” recovery time may be separately billable
• Expected recovery time is considered 4-6 hours
• Physician documentation is essential to reporting of infusions and injections prior to surgery and in recovery. Documentation of medical necessity above and beyond normal treatment is necessary for reporting.

Lori · Aug 24, 2023

Coding Subsequent or Sequential IVPs

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.

https://bok.ahima.org/doc?oid=107707

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)

CPT Coding for Drug Administration

Drug infusion and injection coding requires precision. Here are several tips and tricks you can use to pick the right code every time.

www.aapc.com

CPT® Code	CPT® Description	Notes
96360	Intravenous 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	Intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure)	Report for intervals of greater than 30 minutes beyond one-hour increments; also report for secondary or subsequent service after a different initial service through same IV access.
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 (List separately in addition to code for primary procedure)	Report for intervals of greater than 30 minutes beyond one-hour increments; also report for 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 of a new drug/substance, up to 1 hour (List separately in addition to code for primary procedure)	Report in conjunction with 96365, 96374, 96409, or 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 (multiple drugs mixed together in one bag is one infusate mix).
+96368	Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure)	Report only once per encounter. Report in conjunction with 96365, 96366, 96413, 96415, or 96416. Used for infusions running at the same time via the same IV access—must be hung in separate bags.

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; intravenous, push technique, single or initial substance/drug

+96411

Chemotherapy administration; intravenous, push technique, each additional substance/drug (List separately in addition to code for primary procedure)

Report with 96409 or 96413.

96413

Chemotherapy administration, intravenous infusion technique; 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, or 96375 to identify therapeutic infusion/injection as secondary service through same IV access.

+96415

Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure)

Report in conjunction with 96413.
Report for infusion intervals of greater than 30 minutes beyond one-hour increments.

+96417

Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug) up to 1 hour (List separately in addition to code for primary procedure)

Report in conjunction with 96413.
Report only once per sequential infusion.
Report 96415 for additional hour(s) of sequential infusion.

Single infusion lasting:	Can be coded (assuming documentation is complete):
15 minutes or less	IV push
16 – 90 minutes	Initial hour

GracielaS_18162 · Nov 9, 2023

Lori said:
Documentation:

Physicians/QHPs – Report as infusion or injection based on the physician’s/QHP’s knowledge of the clinical condition(s) and treatment(s)

Facilities – Report based on CPT hierarchy rules:

Chemotherapy services are primary to Therapeutic, Prophylactic and Diagnostic services

Therapeutic, Prophylactic and Diagnostic services are primary to hydration.

The order is:

Chemotherapy

Therapeutic, prophylactic, and diagnostic services

Hydration

Infusions are primary to IV pushes, which are primary to injections. The order is:

Infusions

IV push

Injection

Documentation should support the services reported
• Therapeutic Infusions Hydration
• 1st Hour 16-90 minutes 31-90 minutes
• 2nd Hour 91-150 minutes 91-150 minutes
• 3rd Hour 151-210 minutes 151-210 minutes

Infusion Start / Stop Time
Infusions may be concurrent (i.e., multiple drugs are infused simultaneously through the same line) or sequential (infusion of drugs one after another through the same access site). Selection of the correct CPT code is dependent upon the start and stop time of infusion services. If “stop time” is not documented, only an IV push can be billed. An IV infusion differs from an IV push. An IV push is defined as an infusion lasting 15 minutes or less. Therefore, it is important to use the following guidance:

Infusion services are coded based on the length of the infusion, which is a time-based service.
– 15 minutes or less - Infusions lasting 15 minutes or less would be coded as an IV push
– 16 minutes or more – Infusion codes can be reported after 16 minutes.

The Start and Stop times of each medication administration must be accurately recorded, as this determines the correct CPT code assignment.

The first hour of infusion is weighted heavier than subsequent hours to include preparation time, patient education, and patient assessment prior to and after the infusion.

The time calculations for the length of the infusion should stop when the infusion is discontinued and restart at the time the infusion resumes.

“Initial” service is described as “the service that best describes the key or primary reason for the encounter”
• Order of service delivery does not determine what is “initial” service
• Hierarchy does not apply to Subcutaneous/Intramuscular injections
• Only one per patient encounter UNLESS:
• Two separate IV sites are medically used/necessary
• Patient returns for a separate and medically necessary and reasonable encounter on the same day
• These may be reported with two initial services with a modifier -59 (XE) on the second IV or second encounter

When you bill IV hydration along with IV pushes, always report the IV push as the initial code. According to the CPT hierarchy, the initial
code must be 96374.
• Following that code, 96361 must be assigned for the hydration.

Sequential is when multiple drugs are infused “back to back” or one after the other
• Must be a DIFFERENT drug through the same IV access
• Must be a clinical reason for doing sequential versus concurrent
• 96367 (additional sequential infusion) – report once per drug
• If additional hours of infusion, report 96366

Concurrent is when multiple therapeutic or diagnostic medications (not hydration fluids) are infused simultaneously through separate bags through the same IV line
• Concurrent codes are not to be used for multiple drugs within the same bag
• Typically concurrent is used for “gravity drip” infusion methods
• 96368 (concurrent infusion) - report once per date of service
• If additional hours of infusion, report 96366

Included in the CPT codes – do not bill separately

Local anesthesia
IV start
Access to subcu catheter or port
Flush at the conclusion
Standard tubing
Syringes
Supplies

Infusion time is calculated from the time the administration commences (i.e., the infusion starts dripping) to when it ends (i.e., the infusion stops dripping). Services leading up to the infusion and following the infusion have been included in the infusion code services and are not reported separately.

Health care professional must be continuously present
• Administer the drug
• Observe the patient

Do not report if Infusion of 15 minutes or less.

Do not report injections and infusions given during the course of outpatient surgery and recovery
• Therapeutic IVs and injections given beyond the “normal” recovery time may be separately billable
• Expected recovery time is considered 4-6 hours
• Physician documentation is essential to reporting of infusions and injections prior to surgery and in recovery. Documentation of medical necessity above and beyond normal treatment is necessary for reporting.

Concurrent-
Concurrent administrations that exceed 90 minutes are not reported with the additional hour code 96366

Lori said:
Documentation:

Physicians/QHPs – Report as infusion or injection based on the physician’s/QHP’s knowledge of the clinical condition(s) and treatment(s)

Facilities – Report based on CPT hierarchy rules:

Chemotherapy services are primary to Therapeutic, Prophylactic and Diagnostic services

Therapeutic, Prophylactic and Diagnostic services are primary to hydration.

The order is:

Chemotherapy

Therapeutic, prophylactic, and diagnostic services

Hydration

Infusions are primary to IV pushes, which are primary to injections. The order is:

Infusions

IV push

Injection

Documentation should support the services reported
• Therapeutic Infusions Hydration
• 1st Hour 16-90 minutes 31-90 minutes
• 2nd Hour 91-150 minutes 91-150 minutes
• 3rd Hour 151-210 minutes 151-210 minutes

Infusion Start / Stop Time
Infusions may be concurrent (i.e., multiple drugs are infused simultaneously through the same line) or sequential (infusion of drugs one after another through the same access site). Selection of the correct CPT code is dependent upon the start and stop time of infusion services. If “stop time” is not documented, only an IV push can be billed. An IV infusion differs from an IV push. An IV push is defined as an infusion lasting 15 minutes or less. Therefore, it is important to use the following guidance:

Infusion services are coded based on the length of the infusion, which is a time-based service.
– 15 minutes or less - Infusions lasting 15 minutes or less would be coded as an IV push
– 16 minutes or more – Infusion codes can be reported after 16 minutes.

The Start and Stop times of each medication administration must be accurately recorded, as this determines the correct CPT code assignment.

The first hour of infusion is weighted heavier than subsequent hours to include preparation time, patient education, and patient assessment prior to and after the infusion.

The time calculations for the length of the infusion should stop when the infusion is discontinued and restart at the time the infusion resumes.

“Initial” service is described as “the service that best describes the key or primary reason for the encounter”
• Order of service delivery does not determine what is “initial” service
• Hierarchy does not apply to Subcutaneous/Intramuscular injections
• Only one per patient encounter UNLESS:
• Two separate IV sites are medically used/necessary
• Patient returns for a separate and medically necessary and reasonable encounter on the same day
• These may be reported with two initial services with a modifier -59 (XE) on the second IV or second encounter

When you bill IV hydration along with IV pushes, always report the IV push as the initial code. According to the CPT hierarchy, the initial
code must be 96374.
• Following that code, 96361 must be assigned for the hydration.

Sequential is when multiple drugs are infused “back to back” or one after the other
• Must be a DIFFERENT drug through the same IV access
• Must be a clinical reason for doing sequential versus concurrent
• 96367 (additional sequential infusion) – report once per drug
• If additional hours of infusion, report 96366

Concurrent is when multiple therapeutic or diagnostic medications (not hydration fluids) are infused simultaneously through separate bags through the same IV line
• Concurrent codes are not to be used for multiple drugs within the same bag
• Typically concurrent is used for “gravity drip” infusion methods
• 96368 (concurrent infusion) - report once per date of service
• If additional hours of infusion, report 96366

Included in the CPT codes – do not bill separately

Local anesthesia
IV start
Access to subcu catheter or port
Flush at the conclusion
Standard tubing
Syringes
Supplies

Infusion time is calculated from the time the administration commences (i.e., the infusion starts dripping) to when it ends (i.e., the infusion stops dripping). Services leading up to the infusion and following the infusion have been included in the infusion code services and are not reported separately.

Health care professional must be continuously present
• Administer the drug
• Observe the patient

Do not report if Infusion of 15 minutes or less.

Do not report injections and infusions given during the course of outpatient surgery and recovery
• Therapeutic IVs and injections given beyond the “normal” recovery time may be separately billable
• Expected recovery time is considered 4-6 hours
• Physician documentation is essential to reporting of infusions and injections prior to surgery and in recovery. Documentation of medical necessity above and beyond normal treatment is necessary for reporting.

Concurrent administrations that exceed 90 minutes are not reported with the additional hour code

Alicia · Nov 9, 2023

I hope I am understanding correctly. I am looking at 96366
96366 - Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure)

CPT CodeBook Guidelines:
(Report 96366 in conjunction with 96365, 96367)
(Report 96366 for additional hour of sequential infusion)
(Report 96366 for infusion intervals of greater than 30 minutes beyond 1 hour increments)
(Report 96366 in conjunction with 96365 to identify each second and subsequent infusions of the same drug/substance)

Use code 96365 for an intravenous infusion up to 1 hour. Use add-on code 96366 for each additional hour of the same infusion. Use add-on code 96367 for another, sequential infusion of a different substance or drug for up to 1 hour. Use add-on code 96368 when a different substance or drug is administered at the same time as another drug in a concurrent infusion.

GracielaS_18162 · Nov 9, 2023

Hi, this is regards 96368 (bullet #4)
Concurrent is when multiple therapeutic or diagnostic medications (not hydration fluids) are infused simultaneously through separate bags through the same IV line
• Concurrent codes are not to be used for multiple drugs within the same bag
• Typically concurrent is used for “gravity drip” infusion methods
• 96368 (concurrent infusion) - report once per date of service
• If additional hours of infusion, report 96366- Since 96368 Does not reference a time increment, concurrent administrations that exceed 90 are not reported with the additional hour code 96366?

Alicia · Nov 9, 2023

This is awesome! Thank you for the clarification.

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Resolved Coding Infusions Injections & Hydrotherapy

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Article - Billing and Coding: Infusion, Injection and Hydration Services (A53778)

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Resolved Coding Infusions Injections & Hydrotherapy

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Coding Subsequent or Sequential IVPs​

Hierarchy for Subsequent or Sequential IVPs​

Infusion​

IV Push​

Hydration​

New member

Director of Education

New member

Director of Education

Coding Subsequent or Sequential IVPs

Hierarchy for Subsequent or Sequential IVPs

Infusion

IV Push

Hydration