2006 CPT Coding and Documentation for Drug Administration

2006 CPT Coding and Documentation for Drug Administration Sheila Goethel, RHIT, CCS Rural WI Health Cooperative December 2005 Presentation Objectives Orient to new CPT drug administration codes Provide definitions of new drug administration descriptors Instruct how hospitals will report these new codes and how Medicare claims reporting will be different Provide hands on examples Inform of coding related OPPS updates CMS Reference Claims Processing Manual CMS Claims Processing Manual, 100 Chapter 4, Section 230 Payment for Drug Administration. http://www.cms.hhs.gov/manuals/iom/list.a sp#topofpage 1

Historical Information Q codes originally denoted infusion therapy for Medicare patients when APCs implemented Q codes deleted in 1-1-05 Hospitals reported CPT codes Physicians reported G codes AMA developed new drug administration codes 1-1-06 Hospitals report C codes for Medicare pt Hospitals utilize new CPT codes for Non-Medicare pt Physicians utilize new CPT codes 2005 2006 Time based Non-Chemo Infusion and Chemo infusion Infusion, Push, Injection Time based Hydration, Diagnostic/therapeutic and Chemo Infusion Infusion, Push, Injection Per encounter reporting Per Treatment Identifies the intent for the encounter and captures separate work when different drugs are utilized Why the Granularity of new CPT Codes? MMA also required a study of drug administration items/services furnished by physicians/providers. Analyzing data regarding drug utilization patterns Treads of utilization of drugs/dosages Treatment regimes Selection of higher cost drugs vs low cost drugs Expect to identify cost effective and quality care To obtain this type of information, new infusion codes transition from per encounter to per treatment concept Initial, sequential, concurrent 2

Integral services to infusion/injections Time and resources to start IV Establishment of access to the IV and access to an indwelling IV (Heplock/port) TKO/KVO Flush prior to or at conclusion of infusion Heparin/saline used to cap line is included in the infusion Standard tubing syringes and supplies Preparation of drugs/chemo agent(s) Infusions/injections are integral to anesthesia Hydration IV Info updated on addendum** Saline and/or electrolytes Maximum units = 4; however, to denote multiple units, the service must involve a separate encounter (Transmittal 573) Modifier -59 is reported only to denote separate encounter Hydration IV The addition of saline into a (therapeutic) infusion is considered to be part of the therapeutic infusion code. Fluids provided as the vehicle for the substance infused are considered to be incidental and are; therefore, not separately reported. CPT Asst. Nov 05 Hydration IV code may be reported when hydration prior to or subsequent to (chemo) infusions, but not concurrently Each additional Hydration (90761) may be reported only when provided as a secondary or subsequent service in addition to the initial therapy. 3

Therapeutic, Prophylactic IV Info updated on addendum** Infusion of drugs or other substances Identify the different drugs and the time and resources necessary to provide IV service Maximum units = 4; however to denote multiple units, the service must involve a separate encounter (Transmittal 573) Modifier -59 denotes separate encounter Therapeutic, Prophylactic IV Do not report when inherent of another procedure Fluid/Saline used to administer the drug is incidental hydration and (hydration) is not reported separately. Therapeutic, Prophylactic IV push IV or IA injection by syringe into tubing Injection in which health care professional who administers the substance/drug is continuously present to administer injection and observe patient OR, an Infusion of 15 minutes or less Implies administration completed before caregiver leaves the bedside 4

Therapeutic, Prophylactic & Chemo IV push AMA Descriptions 90774 Therap/Diagnos inject; IV push, single or initial substance/drug 90775 Therap/Diagnos inject; each additional sequential IV push of a new substance/drug (list separately in addition to code for primary procedure) 96409 Chemo adm; IV push, single or initial substance/drug 96411 Chemo adm; IV push, each additional substance/drug (list separately in addition to code for primary procedure) Therapeutic, Prophylactic Injection subq or muscular 90772 replaces both 90782 and 90788 Report 96401/96402 for chemotherapy administration Injection Allergen see 95115-95117 Injection vaccine/toxoid see 90465/6 and 90471/2 Chemotherapy - CPT Subq/IM of hormonal drug Subq/IM of non-hormonal drug IV push 1 st and additional IV piggyback 1 st, each additional, and sequential IA push and IV Intralesional need number of lesions tx Into pleural cavity Into peritoneal cavity Into CNS Injection into subarachnoid or intraventricular Chemo unlisted 5

Chemotherapy - CPT Apply to all neoplastic therapy techniques Separate codes for each method/technique are reportable Administration of other non-chemo drugs administered sequentially or concurrently can be reported separately. Apply to parenteral administration of nonradionuclide anti-neoplastic drugs Apply to anti-neoplastic agents provided for treatment of non-cancer diagnoses (CPT Instruction) - see attachment Cyclophosphamide for auto-immune conditions Brand Name: Cytoxan (Generic Name: Cyclophosphamide) Auto-Immune disorders SLE Sjogren's syndrome Scleroderma MS Monoclonal Antibody agents are provided for numerous conditions To suppress the immune system: OKT3 (Muromonab) for prevention of organ transplant rejection or for Type I DM Xolair (Omalizumab) Allergic asthma Zenapax (Daclizumab) for prevention of kidney transplant rejection and T-cell lymphoma 6

Monoclonal antibodies also provided to: Kill or inhibit malignant cells: Rituxan (Rituximab) B-cell lymphoma Zevalin Lymphomas Bexxar (tositumomab) Lymphoma Herceptin (trastuzumab) Solid tumors Erbitux (cetuximab) Solid tumors Mylotarg AML LymphoCide B-cell Leukemia MabCampath (Alemtuzumab) - CLL Oncolym (Lym-1) Lymphoma Monoclonal antibodies also provided for: Angiogenesis inhibitors: Vitaxin (alpha-v/beta-3) Solid tumors Avastin (Bevacizumab) Colorectal cancer Other: ReoPro (Abciximab) Antiplatlet clumping or for chest pain/coronary intervention Biologic Response Modifiers Enbrel (etanercept) RS, psoriatric arthritis, or ankylosing spondylitis, Humira (adalimumab) slows joint damage in arthritis, RA or psoriatric arthritis Kineret (anakinra) for RA Remicade (Infliximab) RA or for Crohns MGN-3 HIV 7

Chemotherapy ICD dx These previous slides demonstrate that many services, while condition is not neoplastic, CPT reporting will entail the chemo CPT code(s). That is to say that you may be reporting non-neoplasm related ICD dx code(s) with CPT chemotherapy codes. V58 New fifth digits V58.11 (antineoplastic chemo) V58.12 (antineoplastic immunotherapy) See Excludes note under V58.1 Chemotherapy ICD proc Chemotherapy 99.25 Biologic response modifiers - 99.28 Immunotherapy, antineoplastic Low does interleukin-2 Monoclonal antibody agents - 00.15 High dose interleukin-2 Other Chemotherapy Info updated on addendum** Instructional notes indicate 96521-96523 can be reported for therapeutic drugs other than chemo 96521-96522 Refilling/Maint of portable or implantable pump or reservoir 96523 Irrigation of VAD (only reportable if this is the only service provided on that day). Do not report if injection or infusion provided on same day. Flushing (heparin/saline) is integral to injection/infusion. 36550 Decloting by thrombolytic agent of VAD (i.e. Urokinase to declot CPT Asst Nov 99) 8

Initial Service Only one initial drug administration service code is reported per patient per day The initial code best describes the key or primary service the patient is receiving and should be reported irrespective of the order in which the infusions/injections occur. Initial Service Codes 2005 code 2006 code Description 90784 90780 90780 96408 96410 90774 90760 90765 96409 96413 IV push, 1 st drug IV Hydration, 1 st hr IV Therap/diagnos, 1 st hr Chemo IV push, 1 st drug Chemo IV, 1 st hr/drug Each additional List separately in addition to code for the primary procedure Cannot be reported individually These are reported when secondary to the primary procedure Entails additional hours of same (drug) infusion May be reported for those hydration therapies that were secondary to the initial reason for visit No separate APC payment 9

Sequential Denotes a subsequent and separate drug administered beyond the initial administration Two different drugs must be administered to be reported IV push Each additional vs sequential 90774 IV push, single or initial substance/drug 90775 Each additional sequential IV push of a new substance/drug (list separately in addition to code for primary procedure) 96409 Chemo adm; IV push, single or initial substance/drug 96411 Chemo adm; IV push, each additional substance/drug (list separately in addition to code for primary procedure) IV push Each additional vs sequential Info updated on addendum** CPT Asst. Nov 05 informs that 90775 is the addon code for each additional IV injection.?presently, one can infer then that the term sequential within the description does not demand a different drug.?in 2000-2005, there has been no maximum units to multiple IV pushes you could report and be paid for each separate IV push. 10

Concurrent Simultaneous infusion of two nonchemotherapy drugs. Reported only once per encounter (in addition to the initial code) It must be reported as an add-on code. Hydration provided concurrently with chemo is not reported separately If two non-chemotherapy drugs are infused concurrently, report 90765 for the initial drug infused and 90768 as an add-on for the concurrent drug infused. 90768 falls in the category of therapeutic or diagnostic injections and intravenous infusions other than hydration. When one infusion is chemotherapy and one is non-chemotherapy, 90768 can be reported for the non-chemo drug. (Administration of anti-anemia drugs and anti-emetic drugs by injection or infusion for cancer patients is not considered chemotherapy.) There is no concurrent chemo administration code (2 chemo drugs given concurrently). CPT Asst Nov 05 indicates multiple drugs given at same session would not be mixed into same infusion or be given concurrently. However, if done the unlisted chemotherapy administration code 96549 should be reported. Add-On Codes The add-on descriptor does not infer an add-on code of that same primary code. have to be reported with that same drug administration primary code. Subsequent, sequential, and concurrent codes are reported irregardless of the subsection in which the initial service code appears. 11

Add-on Service Codes 2005 90784 90781 90781 90781-96408 96412 96412 2006 90775 90761 90766 90767 90768 96411 96415 96417 Description IV push, each add sequential IV Hydration, each add hr IV diag/ther, each add hr IV diag/ther, addit sequential IV diag/ther, concurrent Chemo push, each add drug Chemo IV, each add Chemo IV, add sequential Other drug adm codes Info updated in addendum** 2005 90782 90788 90799 96400 96400 96414 96520 96530-96549 36550 2006 90772 90772 90779 96401 96402 96416 96521 96522 96523 96549 36550 Description Therap/Diagnostic injection Therap/Diagnostic injection Unlisted therap/diag IV or IA Chemo, sq or musc non-hormon Chemo, sq or musc hormonal Prolonged chemo infusion, 8 hr Refill/maint of portable pump Refill/maint of implant pump Irrigation VAD Unlisted Chemo procedure Declotting with thromoblytic agent Billing Infusion Time If initial hour of infusion only lasts 15 minutes or less, report push technique Infusions up to one hour, report IV infusion code To report add-on codes, infusion must last 30 minutes from the end of the previously billed hour Cannot bill push codes for carry over time not equaling 30 minutes Add-on codes are billed in 8 hour increments (units column on UB) 12

OPPS Final Rule 2006 Maximum units indicated on addendum** All drug administration codes will map to APC groups: 116 ( $68.37) (chemo injection/push) 117 ($189.04) (chemo infusion) 120 ($120.77) (therapeutic/diagnostic infusion) 125 ($113.20) (refilling/maint) 353 ($23.31) (therapeutic IM injection) 359 ($47.82) (therapeutic IV push and IA injection) 352 ($8.14) (Unlisted) OPPS Final Rule Info updated on addendum** Developed and are reviewing advanced OCE claims logic to identify separately payable multiple drug administration services. CMS recognized the potential or returned claims and need to train/educate staff with new codes CMS will adopt 20 of the 33 2006 CPT codes CMS will not recognize 13 of the 33 CPT codes that contain initial, sequential, and concurrent descriptors, but have instructed hospitals to report 6 new C codes for billing/payment purposes CMS is still working on their coding and billing guidelines for reporting drug administration 2006 Medicare Drug Administration Codes Table updated on addendum** 2006 C codes C8950 C8951 C8952 C8953 C8954 C8955 C8956 (?) C8957 Replaces 90760/90765 90761, 90766, 90767 & 90768 90774/90775 96409/96411 96413 96415 95990/96522 - Description IV infusion for therapy/diagnosis; up to 1 hr IV infusion for therapy/diagnosis; each add hr (list separately) Therapeutic, prophylactic or diagnostic injection; IV push Chemo admin; IV push technique Chemo admin IV; infusion technique, up to 1 hr Chemo admin IV; infusion technique, each add hr (list separately) Refill/Maint of portable/implantable pump or reservoir for non-chemo drug delivery for therapy/diagnosis IV infusion for therapy/diagnosis; initiation of prolonged non-chemo infusion (more than 8 hr) requiring use of port/implantable pump 13

Vaccine Administration 2005 G0008 Adm of Influenza Vaccine (No APC pd on reasonable cost) G0009 Adm of Pneumococcal Vaccine (No APC pd on reasonable cost) G0010 Adm of Hep B Vaccine (APC 355 $20.49) 90473/90474 - Intranasal Immunization Adm (No APC excluded from payment) 2006 G0008 Adm of Influenza Vaccine (APC 350 - $23.31) G0009 Adm of Pneumococcal Vaccine (APC 350 - $23.31) 90471/90472 Adm of Hep B vaccine (APC 353 - $23.31) 90473/90474 - Intranasal Immunization Adm (APC 1491 - $5.00) Documentation Requirements Name of Drug Strength of Drug Administration Route Time Started and Ended FOR EACH DRUG ADMINISTERED $If IVPG ($120) is performed without time documented, Coder must default to IV push ($47) code Operational reactions Update your Chargemaster (drug administration and OBS codes) Update your Order entry procedures Revise Parenteral Forms to denote required information see attached Get drug assistance from Physicians (MD order documentation) & from Pharmacists regarding drug type Update P/P to address new processes Educate and train staff Physicians Nursing, Coders, Billers 14

Exercise 1 Lung Cancer patient comes in for chemo 5-FU infusion. Infusion contained concurrent saline with 5-FU. This piggyback infusion lasted 1 hour and 20 minutes. Please provide ICD dx, procedure and CPT code(s): For Medicare patient: For Non-Medicare patient: Exercise 2 2 hour piggyback infusion of Clindamycin antibiotic. Please provide CPT code(s). Medicare patient: Non-Medicare patient: Exercise 3 1 hour piggyback infusion of Antibiotic. When antibiotic totally infused, 1 hour piggyback infusion of Lasix. Please provide CPT codes(s). For Medicare patient: For Non-Medicare patient: 15

Exercise 4 Three IV pushes in ER. The first was Morphine at 10:30, the second was Valium at 10:37 and the third was Lasix at 10:42. Please provide CPT code(s). For Medicare patient: For Non-Medicare patient: Exercise 5 Three IV pushes in ER. The first was Lasix at 10:30, the second was Lasix at 10:37 and the third was Lasix at 10:42. Please provide CPT code(s). For Medicare patient: For Non-Medicare patient: Exercise 6 HIV patient outpatient encounter for Interleukin immunotherapy infusion. Infusion lasted 1 hour and 37 minutes. Patient was dehydrated, so after Interleukin infusion was completed, a saline infusion was provided which lasted 55 minutes. Please provide ICD dx, proc, and CPT code. For Medicare patient: For Non-Medicare patient: 16

Exercise 7 ER patient in cardiac arrest code blue pursued. Patient received Dopamine, Nitroglycerin, and Epinephrine. The Dopamine and Nitroglycerin were IV piggybacks Dopamine started at 1:37 and ended at 2:45. Nitroglycerin started at 1:39 and ended at 2:52. The Epinephrine consisted of three different push techniques (1:40, 1:50 and 2:00) into the tubing. Please report CPT drug administration codes. For Medicare patient: For Non-Medicare patient: Exercise 8 Patient comes in for IV infusion of Remicade (biologic response modifier) for Crohn s disease. IV piggyback starts at 9:15 and ends at 11:24. Patient also receives an IM injection of morphine at 11:10. Please provide ICD dx, proc and CPT code(s). For Medicare patient: For Non-Medicare patient: Exercise 9 Patient with bladder CA comes in for chemotherapy. Patient receives IV piggyback saline (3:10 to 3:50) and IV piggyback Zofran (anti-nausea) (3:52 to 4:48) prior to receiving the chemotherapy. After saline and Zofran, IV piggyback chemotherapy was administered (4:47 to 5:34). Please provide ICD dx, procedure and CPT code(s). For Medicare patient: For Non-Medicare patient: 17

Exercise 10 Patient receives Decadron IV piggyback from 1:00 to 1:25, Benadryl IV piggyback from 1:30 to 1:50 and Pepcid IV piggyback from 1:55 to 2:20. Please provide CPT code(s): For Medicare patient: For Non-Medicare patient: Exercise 11 Patient has a blood transfusion. Your hospital protocol calls for administration of diphenhydramine (drug to prevent reaction) pre and post transfusion for each transfusion. Will you report the IVPG of diphenhydramine separately? Exercise 12 Patient has ALL and and presents for Doxorubicin IVPG. Patient has an infection due to previous VAD site so VAD changed to portable pump. Today, patient presents for Doxorubicin IVPG started at 10:16 am and ended at 12:10 as well as one IV push of Daunorubicin. Patient also given antibiotic in an infusion (portable) pump to take home to be infused in a 10 hour period. (He will be here each day for 2 weeks to obtain this drug for pump refilling). Please provide CPT code(s) For Medicare patient: For Non-Medicare patient: 18

Exercise 13 A patient comes to the hospital with established line used for Rocephin IVPG every other day. Today, on off day, patient enters for flushing of the VAD with normal saline and heparin for patency and to clear the line prior to tomorrow am s infusion. Please provide CPT code: EM Facility Guidelines CMS continues to review AHA and AHIMA s draft of recommended facility EM guidelines and believe additional testing is necessary to ensure accurate information. Once satisfied, CMS will propose guidelines with public comment opportunities to ensue. Anticipate 6-12 months notice prior to implementation to ensure appropriate time to educate staff. Hospitals can be notified of proposal by subscribing to OPPS listserve: http://new.cms.hhs.gov/opendoorforums/18_odf_hospita ls.asp#topofpage Current proposed guidelines http://www.ahima.org/pdf_files/emcodingreport.pdf Observation (OPPS) Eliminate current three G codes (G0244, G0263, G0264) and replace with two new G codes- G0378- Hospital observation services, per hour G0379- Direct admission of patient for hospital observation care CMS will incorporate claims intelligence (OCE) to determine observation payment status, as opposed to hospitals currently having to make that determination 19

Inpatient Only List (OPPS) Removal of 26 procedures, which are now reimbursable under OPPS (SI=T) Modifier 52, 73, & 74 reimbursement Currently pay Modifier 52 at 100%, but will only reimburse at 50% after 1-1-06 Continue to pay 50% of those reported with modifier -73 Continue to pay 100% for those reported with modifier -74 Status Indicators Add Q Packaged service subject to separate payment under OPPS. Addendum B displays APC assignment if/when service is performed individually. If performed with another service, that SI Q procedure will be packaged. Add M Service not billable to FI Revised H and K pass-through/non passthrough categories Foley Cath codes not packaged (51701 & 51702 to SI X and 51703 to SI T) 20

Web Addresses/References Info updated on addendum** Federal Register, November 10, 2005 http://a257.g.akamaitech.net/7/257/2422/01jan20051800/ed ocket.access.gpo.gov/2005/pdf/05-22136.pdf CMS Transmittals http://new.cms.hhs.gov/transmittals/ Drug Administration Transmittal Medicare Claims Processing Manual Chapter 4 section 230.2 http://www.cms.hhs.gov/manuals/iom/list.asp#topofpage UGS Medicare Memo June 2005 http://www.ugsmedicare.com/providers/medicare_memos/200 5/documents/2005-6.0.pdf CPT Asst. November 05 pg 1-9 CMS Open Door Registration http://www.cms.hhs.gov/opendoorforums/18_odf_hospitals. asp Questions? Thank you! Certificate of Attendance: This Certificate is Awarded to: In recognition of participation in the: 2006 CPT Coding and Documentation for Drug Administration 3 hour webinar presentation on December 2005 (3 CDM Continuing Education Hours) Sheila Goethel, RHIT, CCS RWHC Coding Consultant 21