Infuse Yourself with Knowledge on Reporting Therapeutic, Prophylactic, and Diagnostic Injection Services

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Apr 19th, 2022

Some fluids, substances, and drugs must be administered intravenously (IV), meaning into the vein. An IV is started by inserting a needle into a vein at the wrist, elbow, or back of the hand and then inserting a catheter over the needle and into the vein and the needle is then removed. While the catheter remains in the vein, the end is closed off to prevent infection and the access cap used to facilitate administration of the substances. Often, circumstances call for a mix of infusions and injections, which is why these services are grouped together under the title of therapeutic, prophylactic, and diagnostic injections and infusions, as follows:

Note: Substances administered intra-arterially (directly into the artery) are reported with 96376.

Method or Delivery Route

These services describe substances, fluids, or drugs administered to the patient through the following delivery routes: 

• Injections:
  • Subcutaneous (SQ): Through a needle inserted under the skin
  • Intramuscularly (IM): Through a needle inserted into a muscle
• IV infusion: Controlled administration of a substance, fluid, or drug directly into the bloodstream through an established intravenous line. The two main methods of IV infusion include:
  • IV Drip: Using gravity to deliver the substance at a consistent dose over a set period of time.
  • IV Pump: A pump is attached to the IV line and used to administer the substance, fluid, or drug mixed into a solution into the vein in a slow and steady fashion.
  • IV push or bolus: Rapid injection of the substance directly into the vein through an established IV line over a shorter period of time, less than 15 minutes.
  • Intra-arterial: Administered directly into the body through an artery 

Note: Understanding the method or route of delivery is vital to selecting the correct codes. 

Medical Documentation

The medical record should contain all the information needed to identify the service provided, justify medical necessity for it, and identify not only the patient’s information but also the service provider’s information, signatures, and dates.

Written and Verbal Orders

Physician’s orders are part of the medical record and are required for the infusion or injection service to be performed. Prior to administration of a substance, fluid, or drug, a written or verbal order for the service must be given by a physician or other qualified healthcare practitioner (QHP). While some orders are verbally given to nursing staff who are qualified to receive the order and carry it out, all verbal orders must be authenticated in the medical record within 48 hours. According to CMS, 

When reviewing the documentation, look first for the order, which needs to include: 

• Date
• Patient identifying information
• Drug or substance to be administered, including strength and dosage
• Route of administration, including details like rate, flow, etc.
• Physician/QHP signature with a legible printed name and date signed 

If the order was given verbally, look for the nurse's documentation of the verbal order to see that it has been documented properly, signed, and dated by the receiving nurse. Then look for the authenticated order and compare the two to ensure they match. To verify, look for the nurse's note of what was administered to ensure it also matches the order and contains the vital details required to qualify for reporting. While physicians/QHPs often administer infusions in the office setting, clinical staff (e.g., medical assistant) often administer injections under the direct supervision of the physician/QHP. 

In the facility setting, nursing staff administer infusions and injections under the general supervision of the physician/QHP. The administering staff member is responsible for accurately documenting the service provided, including date and signature and details, such as:

• Substance administered, strength, dose, and lot number
• Method or route of delivery (e.g., IV push, IM injection) and rate of administration
• Location (e.g., right arm, left deltoid)
• Outcome or post-infusion/injection patient status (e.g., patient tolerated well)
• Start/stop times for each substance administered
• Performing staff member’s signature, legibly printed name, title, and date of signature

Infusion Services are Timed Services

As noted above, the documentation for all infusion services must include both the start and stop times for each individual substance administered. These are required in order to select the correct code for reporting the service. If the start of stop time is missing for any substance, the infusion will be reported as an injection instead, which can be a costly mistake. As seen in the example below, the stop time for the initial drug infused is missing, which reduces the service for that drug to a simple injection

Example:

• Levaquin was administered via infusion at 1:00 pm (missing the stop time)
• Reglan was infused starting at 2:10 pm and stopped at 3:30 pm. 

Another purpose for documenting the start/stop times is for proper calculation of the number of units for each service to be reported, and when they qualify for reporting. If a therapeutic dose of Rocephin was administered via IV infusion with documented time of start:10:02 stop: 11:15 (total of 73 minutes) this would qualify for one unit of 96365, the initial therapeutic IV infusion service. In order to qualify for 1 unit of the add-on code (96366), a total of 91 minutes would have had to be documented.

Infusion and Injection Reporting Hierarchy

For reporting purposes, infusions and injections adhere to the following reporting hierarchy: 

Note: The order in which the substances/drugs are administered does not dictate the order in which they are reported. 

Bundled Services
When performed as part of the infusion or injection service, the following services and equipment are considered bundled into the infusion/injection service and are not separately reported: 

• Local anesthetic
• Starting the IV (e.g., needle placement, attaching tubing)
• Accessing the IV, subcutaneous catheter, and/or port
• Flushing the IV line at the end of the infusion
• Standard IV tubing, equipment, supplies, and/or syringes

When a patient presents for a scheduled infusion or injection service, the E/M service performed by the physician/QHP is bundled into the infusion/injection service as the preoperative work. However, if a significantly and separately identifiable E/M service is performed in which the decision for the infusion or injection service was made or evaluation of another problem was documented, it may be appropriate to report the E/M encounter with modifier 25 to override the edit. 

Report Only A Single Initial Infusion Service
When multiple infusion services are reported, only a single “initial” infusion service may be reported and all remaining infusion services are reported with the add-on code that accurately describes the service, as follows: 

If all three services were performed for one hour, the coder would follow the hierarchy order for reporting, which dictates the chemotherapy initial hour is reported first. Once the initial service is reported, all other substances infused are reported with the “each additional” add-on code for their infusion type, which would be 96413, 96366, 96361. 

Documented time dictates when the add-on infusion service code can be reported. Code 96365 is reported for the initial 60 minutes, and 96366 is reported for the subsequent 60 minutes of infusion of the same substance. As a timed service, the add-on code (96366) can only be reported after more than half of the time (or an additional 31 minutes beyond the initial service of 60 minutes) has been completed or a total of 91 minutes.

IV infusion service (+96367) is reported when an IV infusion of a NEW substance is documented. For example, if the documentation supports 120 minutes of IV infusion of Vancomycin and IV infusion of odansetron for a total of 74 minutes, the following would be reported: 

• 96365 x 1 unit (first 60 minutes of Vancomycin)
• 96366 x 1 unit (next 60 minutes of Vancomycin-same substance)
• 96367 x 1 unit ( IV infusion of odansetron-new substance)

Concurrent Infusion

There is an add-on code for reporting an infusion of a new substance/drug that is infused at the same time as another substance or drug. Concurrent infusions are not a time-based service, and so may be applicable for infusions that are more than 15 minutes but less than the minimum of 31 minutes required for 96365, 96366, 96367. Concurrent infusion services may only be reported once per day, regardless of more than one new drug/substance having been administered concurrently.

IV Push

An IV push or bolus describes a medication that is injected through an IV access site rapidly, in 15 minutes or less. Once the infusion time reaches 16 minutes, it is no longer considered an IV push but rather is an infusion. Once again, the documentation of start/stop times is vital to determine whether an infusion or IV push will be reported. Creating a best-practices policy that requires documentation of the start/stop times for every substance infused is a great way to support proper coding. 

Therapeutic, Prophylactic, and Diagnostic Injection Coding Scenario

The following scenario may help illustrate the coding requirements: 

Scenario: The following drugs were administered to the patient by IV infusion. For the ease of understanding of the example, times are noted in total minutes instead of start/stop.

1. Therapeutic drug #1: IV infusion for 65 minutes
2. Normal saline was used to flush the IV line (not reportable)
3. Therapeutic drug #2: IV infusion (same site, new drug) for 110 minutes
4. Normal saline was used to flush the IV line (not reportable)
5. Prophylactic drug #3: IV infusion (same site, new drug) for 14 minutes

Codes: 96365 x1, 96366 x 1 (Drug#2), 96367 x 1 (Drug#1), 96374 x 1 (Drug#3 IV Push)

Explanation: Flushing the line with normal saline is not a reportable service (see CPT guidelines for 96360). Both Drug#1 and Drug#2 are therapeutic and prophylactic, so hierarchy does not come into play and they are reported in the way that best fits the scenario. Drug #3 is an infusion of 15 minutes or less qualifying as an IV push.

Resources:

• Current Procedural Terminology (CPT), 2022
• Code of Federal Regulations

About Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Aimee L. Wilcox is a medical coding, billing, and auditing consultant, author, and educator with more than 30 years of clinical and administrative experience in healthcare, coding, billing, and auditing. Medicine, including coding and billing, is a constantly changing field full of challenges and learning and she loves both. Aimee believes there are talented medical professionals who, with proper training and excellent information, can continue to practice the art of healing while feeling secure in their billing and reimbursement for such care.