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Q: Do we code injections of insulin while the patient is (in)observation (status) when it would be part of their daily medication regimen if they were home?


A: Insulin is considered self-administrable from CMS and is statutorily non-covered. However, many of the commercial payers may pay for this. It usually comes down to a facility determination on how to handle this since Medicare states insulin is non-covered and typically the administration is non-covered. You may need to have an internal discussion on this.


Q: For an observation patient, if a patient receives the same medication on different dates of service should we code a 96374 on the new date or continue with 96376?


A: Observation and meds on different dates – codes are assigned based on the encounter or visit and not per date for observation services, so there should only be one initial.



Q: If a patient receives the same medication in an infusion on the same day, but later on that day – what is the second code if 96365 Initial IV infusion is coded first? Would it be another initial infusion 96365 code?


A: Same medication twice a day – this depends upon if it is during the same encounter or different encounters. If during the same encounter there will be only one initial – if different encounters, meaning that the patient left and came back, then two initials with the modifier 59 on the second initial.



Q: The in-service you presented yesterday indicated there needed to be medical necessity to code hydration services; i.e., nausea & vomiting, etc. Does the documentation have to state “hydration” in order to code hydration? Some of our coders interpreted this meaning and others thought we only needed to see the diagnoses to support a hydration service.


A: Hydration – I have not seen any documentation that states that the physician has to state “hydration.” The key is knowing the clinical indicators for hydration services or understanding when hydration is the treatment for a specific condition and making sure that the physician documentation supports hydration.



Q: Can a facility code infusions started in the emergency room on an inpatient if we are already coding a facility E&M level?


Is this only done for reporting purposes, or are there insurance companies that may pay for this procedure?


A: Inpatient. When a patient presents to the ED and is treated, this is considered an OP so we would begin to charge and report those services. When a decision is made to admit the patient to IP status, the OP charging is stopped and all of the charges will roll to the IP DRG or other payment from other commercial payers.



Q: What is definition of “sequential” and can you give us an example?


A: Sequential is a drug that is given after another drug. Per the CPT Code description this is of another or different infusate (drug). Example is in the slide presentation, slide No. 14.



Q: What is definition of “concurrent” and can you give us an example?


A: Concurrent is a drug that is given at the same time through the same line. Example is in the slide presentation, slide No. 16



Q: When there are hours in between infusions, is the next dose a sequential?


A: Hours between infusion – if it is the same drug given then you are just adding the time up and reporting each additional hour. If it is a different drug then it is sequential.



Q: If a patient has an infusion today and has the same drug tomorrow, do you code as another initial or a sequential the next day?


A: Infusion today, same drug tomorrow – if same encounter or visit, code additional hour of infusion. If different encounter or visit then another initial with modifier 59.



Q: If a patent has an IV push today and has the same drug tomorrow, do you code as another initial or a sequential the next day?


A: Same IVP. If same encounter or visit, code 96376 if 30 minutes of time or greater has passed. If different encounter or visit then another initial with modifier 59.



Q: Why is a -59 modifier needed when you are doing a sequential infusion in single site since there is a CPT code that says sequential infusion?


A: Depends upon the other codes assigned. Maybe looking to determine that the sequential infusion is of a different infusate and not the same drug.



Q: Question on units for hydration. Example: chemo infusion of 30 minutes 96413; chemo IV push 96411 and non-chemo IV push 96375 and five hours of medically necessary hydration. Is this five hours of hydration, or must 91 minutes be subtracted before counting units of hydration?


A: Based on your information, if the hydration is performed before or after the chemo then five hours of time is assigned. However, if the hydration is performed during the chemo and the fluid is used to infuse the chemo agent, you may need to remove the time for the chemo administration. It is difficult to assess without seeing the patient record.



Q: Can you speak to billing and coverage for chemo or blood transfusions that are provided in a transitional care unit?


A: If billed as part of the hospital services then you can bill for the blood and chemo. I am not a specialist in billing for skilled services, (so) I cannot really address that side of the question.



Q: Does the same apply to blood transfusion for an observation patient? Can you bill observation hours and blood administration time for the same hours?


A: You need to determine if “active monitoring” is taking place, and if so then you would need to subtract the time for the transfusion from the observation time.



Q: What do you suggest we do for infusion services that are being provided during a carved-out procedure in OBS time?


A: If the infusion service is tied to the carved-out procedure then it also must be subtracted from the observation time. If, however, the infusion service is not part of the procedure in which active monitoring is taking place, you can bill for the infusion. Documentation must support that it is not part of the procedure.



Q: Thanks for answering the question regarding (admission) from the ER. But can you define what determines the time of the inpatient admit? When they hit the inpatient bed? Doctor order? Thanks.


A: Inpatient status begins when the order is written for IP admission.




Q: Would you comment on SQ insulin injections? Is each injection separately chargeable? Thank you.


A: Insulin is considered self-administrable for Medicare encounters and non-covered, therefore the administration is typically non-covered also. For other commercial payers they may pay, depending upon your contracts. Facilities need to determine how to handle insulin injections as this is an area that patients tend to complain about when billed for. However, if they are a Medicare beneficiary it is in their benefit policy and they should be aware of this.


About the Author


Peggy M. Hapner, RHIA, CCS, CASCC, consulting services manager for Medical Learning Incorporated, has more than 20 years of experience in health information management, coding, teaching, data quality and operations. In addition to her bachelor of science in allied health professions (medical record administration division), she is a registered health information administrator (RHIA), a certified coding specialist (CCS) and a certified Ambulatory Surgery Center coder (CASCC). Professional affiliations include the American Health Information Management Association (AHIMA), Ohio Health Information Management Association, Miami Valley Health Information Management Association and the American Academy of Professional Coders (AAPC). At MedLearn, Peg contributes to projects in consulting, seminars and publications divisions.


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