Hydration, IV Infusions, Injections and Vaccine Charge Process

Transcription

1 There are a number of items to be considered when billing for the Nursing service to perform drug therapy, the charge process is divided into three specific groups of codes and processes. 1. Hydration and IV Therapy 2. Injections into IV lines and intramuscular 3. Vaccines Hydration and IV Therapy: Hydration and IV therapy are time based charges, which have a first hour and a subsequent hour. The codes are as follows: Intravenous infusion, hydration; initial, 31 minutes to 1 hour Intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure), the additional time has to be greater than 30 minutes Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour, minutes (less than 16 min = IVP) Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure) Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion, up to 1 hour (List separately in addition to code for primary procedure), minutes and a different drug Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure), once per encounter Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to 1 hour, including pump set up and establishment of subcutaneous infusion site(s), minutes Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure), must be greater than 30 minutes Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); additional pump set up with establishment of new subcutaneous infusion site(s) (List separately in addition to code for primary procedure), once per encounter Hydration therapy must last longer than 30 minutes, to be considered for an initial 1 st hour code. IV therapy less than 16 minutes is to be coded as an IV injection. Hydration less than 30 minutes is not a billable procedure. Establishing a heparin or saline lock for access or a slow drip of saline for access is not hydration or IV therapy. PARA Healthcare Financial Services March 2012 Page 1

2 Injections into IV lines are required to be classed into the following codes: 1. Initial injection med A (96374) 2. Additional subsequent injection, meds B Z (96375) 3. Additional subsequent injections med A (96376), there must be a period of more than 30 minutes that has to pass between injections of same drug. The codes used for IV injections are as follows: Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug 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) Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility (List separately in addition to code for primary procedure) see time note above Intramuscular, subcutaneous and intra arterial injections use the following codes: Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intra arterial Vaccines are based on the number of injections and for Medicare the type of vaccine: Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid) Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) G0008 / G9141 ADMINISTRATION OF INFLUENZA VIRUS / H1N1 VACCINE G0009 ADMINISTRATION OF PNEUMOCOCCAL VACCINE G0010 ADMINISTRATION OF HEPATITIS B VACCINE not billable hospital outpatient Part B PARA Healthcare Financial Services March 2012 Page 2

3 General rules: There can only be one initial procedure, on a claim / encounter. The ranking to determine the initial procedure is as follows, the remaining procedures must be coded as additional or subsequent. 1. Chemotherapy services 2. IV therapy 1 st hour IV injection initial 4. Any other infusion/iv therapy code precedes a hydration code Hydration 1 st hour this code used as initial only if NO OTHER drug is administered as an infusion or IV therapy Establishing IV access is not hydration or IV therapy. Hydration procedures must have a diagnosis supporting the procedure, hydration substances include normal saline, D5W, and pre packaged KCL. Initial IV therapy must last longer than 15minutes, but if less than 16 minutes, the procedure should be charged as an IV injection. Drug admin charges are only reported on outpatient/ambulatory care, emergency and observation patients, the service is not charged on inpatients. There are a number of different revenue codes which can be used to report these services; the basic guideline is to list the charge against the nursing station providing the service. For the charge for an additional hour of hydration or IV med therapy the service must last for more than 30 minutes into the additional hour IV Therapy General Classification 0450 Emergency Room General Classification 0456 Emergency Room Urgent Care 0510 Clinic General Classification 0516 Clinic Urgent Care Clinic 0761 Treatment or Observation Room Treatment Room 0762 Treatment or Observation Room Observation Room 0940 Other Therapeutic Services General Classification PARA Healthcare Financial Services March 2012 Page 3

4 General rules (continued): If performed to facilitate the infusion or injection, the following services are included and are not reported separately referenced in AMA CPT Nomenclature: 1. Use of local anesthesia 2. IV start 3. Access to indwelling IV, subcutaneous catheter or port 4. Flush at conclusion of infusion 5. Standard tubing, syringes, and supplies For Declotting of a catheter or port, use The definition of when a chemo code is to be billed instead of an IV med therapy is a function of the requirements of the drug preparation and the Nurse performing the procedure. A quote from AMA CPT: See codes for the administration of chemotherapy or other highly complex drug or highly complex biologic agent services. These highly complex services require advanced practice training and competency for Staff who provide these services; special consideration for the preparation, dosage or disposal; and commonly, these services entail significant patient risk and frequent monitoring. Examples are frequent changes in the infusion rate, prolonged presence of nurse administering the solution for patient monitoring and infusion adjustments, and frequent conferring with the physician about these issues. PARA Healthcare Financial Services March 2012 Page 4

5 Vaccines: The codes associated with vaccine administration are as follows: These codes are for the Nursing service, the drug costs are to be attached to the product codes , sample pasted below. PARA Healthcare Financial Services March 2012 Page 5

6 Complex drugs and biologic agents are to be billed using the chemotherapy codes: Chemotherapy administration, subcutaneous or intramuscular; non hormonal anti neoplastic Chemotherapy administration, subcutaneous or intramuscular; hormonal anti neoplastic Chemotherapy administration; intralesional, up to and including 7 lesions Chemotherapy administration; intralesional, more than 7 lesions Chemotherapy administration; intravenous, push technique, single or initial substance/drug Chemotherapy administration; intravenous, push technique, each additional substance/drug (List separately in addition to code for primary procedure) Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure) Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump 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) Chemotherapy administration, intra arterial; push technique Chemotherapy administration, intra arterial; infusion technique, up to 1 hour Chemotherapy administration, intra arterial; infusion technique, each additional hour (List separately in addition to code for primary procedure) Chemotherapy administration, intra arterial; infusion technique, initiation of prolonged infusion (more than 8 hours), requiring the use of a portable or implantable pump Chemotherapy administration into pleural cavity, requiring and including thoracentesis Chemotherapy administration into peritoneal cavity via indwelling port or catheter Chemotherapy administration, into CNS (eg, intrathecal), requiring and including spinal puncture PARA Healthcare Financial Services March 2012 Page 6

7 Drugs and Biologicals related to Chemotherapy Table A. Limited coverage is being established by CMS for these drugs on List A C9257 INJECTION, BEVACIZUMAB, 0.25 MG J0894 INJECTION, DECITABINE, 1 MG J9001 INJECTION, DOXORUBICIN HYDROCHLORIDE, ALL LIPID FORMULATIONS, 10 MG J9010 INJECTION, ALEMTUZUMAB, 10 MG J9015 INJECTION, ALDESLEUKIN, PER SINGLE USE VIAL J9017 INJECTION, ARSENIC TRIOXIDE, 1 MG J9025 INJECTION, AZACITIDINE, 1 MG J9033 INJECTION, BENDAMUSTINE HCL, 1 MG J9035 INJECTION, BEVACIZUMAB, 10 MG J9041 INJECTION, BORTEZOMIB, 0.1 MG J9043 INJECTION, CABAZITAXEL, 1 MG J9171 INJECTION, DOCETAXEL, 1 MG J9179 INJECTION, ERIBULIN MESYLATE, 0.1 MG J9201 INJECTION, GEMCITABINE HYDROCHLORIDE, 200 MG J9206 INJECTION, IRINOTECAN, 20 MG J9207 INJECTION, IXABEPILONE, 1 MG J9214 INJECTION, INTERFERON, ALFA 2B, RECOMBINANT, 1 MILLION UNITS J9228 INJECTION, IPILIMUMAB, 1 MG J9263 INJECTION, OXALIPLATIN, 0.5 MG J9264 INJECTION, PACLITAXEL PROTEIN BOUND PARTICLES, 1 MG J9265 INJECTION, PACLITAXEL, 30 MG J9302 INJECTION, OFATUMUMAB, 10 MG J9305 INJECTION, PEMETREXED, 10 MG J9310 INJECTION, RITUXIMAB, 100 MG J9330 INJECTION, TEMSIROLIMUS, 1 MG J9351 INJECTION, TOPOTECAN, 0.1 MG J9395 INJECTION, FULVESTRANT, 25 MG J9999 NOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC DRUGS PARA Healthcare Financial Services March 2012 Page 7

8 Drugs and Biologicals related to Chemotherapy (continued) Table B. The FI/Contractor expects the use of these drugs on List B will be reasonable and necessary J9000 INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG J9020 INJECTION, ASPARAGINASE, 10,000 UNITS J9027 INJECTION, CLOFARABINE, 1 MG J9031 BCG (INTRAVESICAL) PER INSTILLATION J9040 INJECTION, BLEOMYCIN SULFATE, 15 UNITS J9045 INJECTION, CARBOPLATIN, 50 MG J9050 INJECTION, CARMUSTINE, 100 MG J9055 INJECTION, CETUXIMAB, 10 MG J9060 INJECTION, CISPLATIN, POWDER OR SOLUTION, 10 MG J9065 INJECTION, CLADRIBINE, PER 1 MG J9070 CYCLOPHOSPHAMIDE, 100 MG J9098 INJECTION, CYTARABINE LIPOSOME, 10 MG J9100 INJECTION, CYTARABINE, 100 MG J9120 INJECTION, DACTINOMYCIN, 0.5 MG J9130 DACARBAZINE, 100 MG J9150 INJECTION, DAUNORUBICIN, 10 MG J9151 INJECTION, DAUNORUBICIN CITRATE, LIPOSOMAL FORMULATION, 10 MG J9160 INJECTION, DENILEUKIN DIFTITOX, 300 MICROGRAMS PARA Healthcare Financial Services March 2012 Page 8

9 Drugs and Biologicals related to Chemotherapy (Table B continued) J9165 INJECTION, DIETHYLSTILBESTROL DIPHOSPHATE, 250 MG J9178 INJECTION, EPIRUBICIN HCL, 2 MG J9181 INJECTION, ETOPOSIDE, 10 MG J9185 INJECTION, FLUDARABINE PHOSPHATE, 50 MG J9190 INJECTION, FLUOROURACIL, 500 MG J9200 INJECTION, FLOXURIDINE, 500 MG J9208 INJECTION, IFOSFAMIDE, 1 GRAM J9209 INJECTION, MESNA, 200 MG J9211 INJECTION, IDARUBICIN HYDROCHLORIDE, 5 MG J9215 INJECTION, INTERFERON, ALFA N3, (HUMAN LEUKOCYTE DERIVED), 250,000 IU J9230 INJECTION, MECHLORETHAMINE HYDROCHLORIDE, (NITROGEN MUSTARD), 10 MG J9245 INJECTION, MELPHALAN HYDROCHLORIDE, 50 MG J9250 METHOTREXATE SODIUM, 5 MG J9260 METHOTREXATE SODIUM, 50 MG J9261 INJECTION, NELARABINE, 50 MG J9266 INJECTION, PEGASPARGASE, PER SINGLE DOSE VIAL J9268 INJECTION, PENTOSTATIN, 10 MG J9270 INJECTION, PLICAMYCIN, 2.5 MG PARA Healthcare Financial Services March 2012 Page 9

10 Drugs and Biologicals related to Chemotherapy (Table B continued) J9280 MITOMYCIN, 5 MG J9293 INJECTION, MITOXANTRONE HYDROCHLORIDE, PER 5 MG J9300 INJECTION, GEMTUZUMAB OZOGAMICIN, 5 MG J9303 INJECTION, PANITUMUMAB, 10 MG J9320 INJECTION, STREPTOZOCIN, 1 GRAM J9340 INJECTION, THIOTEPA, 15 MG J9357 INJECTION, VALRUBICIN, INTRAVESICAL, 200 MG J9360 INJECTION, VINBLASTINE SULFATE, 1 MG J9370 VINCRISTINE SULFATE, 1 MG J9390 INJECTION, VINORELBINE TARTRATE, 10 MG J9600 INJECTION, PORFIMER SODIUM, 75 MG PARA Healthcare Financial Services March 2012 Page 10

11 Drugs and Biologicals outside the 9000 range Table C. These drugs can be billed with Chemo Administration codes J0128 INJECTION, ABARELIX, 10 MG J0215 INJECTION, ALEFACEPT, 0.5 MG J0970 INJECTION, ESTRADIOL VALERATE, UP TO 40 MG J1000 INJECTION, DEPO ESTRADIOL CYPIONATE, UP TO 5 MG J1380 INJECTION, ESTRADIOL VALERATE, UP TO 10 MG J1390 INJECTION, ESTRADIOL VALERATE, UP TO 20 MG J1410 INJECTION, ESTROGEN CONJUGATED, PER 25 MG J1435 INJECTION, ESTRONE, PER 1 MG J3315 INJECTION, TRIPTORELIN PAMOATE, 3.75 MG J7516 CYCLOSPORIN, PARENTERAL, 250 MG J7525 TACROLIMUS, PARENTERAL, 5 MG J9355 INJECTION, TRASTUZUMAB, 10 MG Q3025 INJECTION, INTERFERON BETA 1A, 11 MCG FOR INTRAMUSCULAR USE PARA Healthcare Financial Services March 2012 Page 11

12 Billing Examples Service Billing Codes Billing Code Description 1. Patient receives a saline/hep lock for access None Insertion of an access site catheter does not create a billable event 2. Patient receives infusion TKO at a rate of 100 ml/hr for a period of 2 hours None Infusion of a fluid for access TKO/KVO is not a billable event 3. Patient receives a hydration infusion "bolus" of less than 30 minutes None Hydration must last longer than 30 minutes to be billable 4. Patient receives a med infusion of less than 16 minutes Med infusions less than 16 minutes are to be billed as a IVP injection 5. Patient receives hydration of 89 minutes Patient is to be billed for 1 hour hydration, additional hours require greater than 30 minutes of additional time 6. Patient receives hydration for 45 minutes and a med injection into the IV line, there is not a medical condition to require the hydration If the hydration is only a method to admin the drug through the IV line the Patient should only be billed for the IV injection, but not the infusion 7. Patient receives hydration for 45 minutes and a med injection into the IV line, there is a medical condition to require the hydration If there is a medical requirement for the hydration, then both codes are billable, bill only one initial per encounter, IVP outranks hydration 8. Patient receives IV infusion for 91 minutes, on the 45th minute the Patient receives a 2nd med same site / line infusion for 45 minutes Patient is to be billed for 1st hour med infusion, additional hour infusion (greater than 30 minutes), and 1 hour concurrent med infusion PARA Healthcare Financial Services March 2012 Page 12

13 9. Patient receives IV infusion for 90 minutes, on the 91st minute the Patient receives a 2nd med same site for 45 minutes Patient is to be billed for 1st hour med infusion, and 1 hour sequential med infusion, 2nd hour infusion requires greater than 30 minutes 10. Patient receives IV infusion for 91 minutes, the Patient then receives a 2nd med, new site and pump for 45 minutes Patient is to be billed for 1st hour med infusion, add hour infusion, and 1 hour sequential med infusion new site 11. Patient receives med infusion for 45 minutes, and a 2nd drug is injected into the IV line Patient is to be billed for a IV med infusion, plus a IV injection, only one initial code per encounter 12. Patient receives med infusion for 45 minutes, and a 2nd drug is injection into the IV line, and then 31 minutes later the same drug is injected into the IV line Patient is to be billed for IV med infusion, injection of a drug into IV line, and then the same drug injected into a IV line, outside the 30 minute inclusion limit 13. Patient receives med infusion for 45 minutes, and a 2nd drug is injection into the IV line, and then 20 minutes later the same drug is injected into the IV line Patient is to be billed for IV med infusion, injection of a drug into IV line, because the same drug was injected within 30 minutes no additional code(s) 14. Patient receives med infusion for 45 minutes, and a 2nd drug is injected into the IV line, and then a 3rd drug is injected into the IV line x 2 Patient is to be billed for a IV med infusion, injection into a IV line, and sequential drug injection into a IV line 15. Patient is injected a pain med IM and then also a vaccine Patient is to be billed im injection and a vaccine admin injection 16. Patient is injected the same drug twice IM 15 minutes apart x 2 Patient is to be billed the im injection twice PARA Healthcare Financial Services March 2012 Page 13