Billing and Coding: Infusion, Injection and Hydration Services

Palmetto GBA has received inquiries related to the billing and documentation
of infusions, injections and hydration fluids. Documentation, medical
necessity, and code assignment are very important.  
  
 **Infusion Therapy**  
  
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 time of initiation,
time of completion, and discharge from the outpatient facility.  
  
Intravenous (IV) infusions are billed based upon 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 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.  
  
**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  
  
**Hydration Therapy**  
  
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.  
  
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.  

**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  
  
 **Recommended Documentation Plan**  
  
Develop and/or revise documentation forms that conform to the coding
guidelines for injections, IV pushes, and IV infusions  
Clinical personnel should focus on patient care and ensure accurate and
complete documentation of the encounter  
The pharmacist should communicate the classification of the 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
the 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