When I audit services performed in an infusion center, I’m addressing two key questions. First, were all of the patient’s infusion, injection, and/or hydration services documented appropriately for what is being billed? Second, if evaluation and management services were performed, were they medically necessary and separate and distinct from the infusion center services for which the patient is being seen on the service day
Let’s talk about both of these key areas, starting with the infusion, injection or hydration services.
I start by reviewing the physician’s orders to see which drugs were ordered for the patient, the dosage and the reason for the administration of the drug, which is typically the diagnosis coding. This seems like a small step, but the accuracy of the orders is a key part of ensuring the service is being properly done in alignment with the provider’s wishes.
Next, I want to identify the basic patient details as part of the encounter for each substance that enters the patient. This includes:
- Drugs or substances administered
- Mode of administration (injection/infusion/push etc.)
- Access site
- Start and stop times for each substance-infused
- Rate of administration – slower hydration, for example, should have a documented reason
- Dose and volume of the drug
- Evidence the line was flushed upon completion
- Any wastage of the drug for billing purposes (note that modifier JW is applied at the claim line level to represent discarded drug and modifier JZ is for situations where there is no wastage in a single-use vial).
When multiple substances are administered to the patient, only one ‘initial’ code is used, based on the drug that represents the best or most appropriate reason why the patient was seen. There can only be a second initial code if the patient returns for a separate, medically necessary service on the same day OR if two separate sites are medically necessary. Modifier 59 is appropriate for these cases.
The typical hierarchy for initial services is infusion (which must be greater than 15 minutes), followed by injections/pushes, followed by hydration. Chemotherapy would be primary to diagnostic, therapeutic, or prophylactic infusions, injections, or pushes.
An infusion of 15 minutes or less is considered a push for code selection purposes. Beyond this requirement, time-based codes require you to exceed half of the typical time. So a one-hour infusion code is used for infusions lasting 16-90 minutes and the second hour code is used 91-150 minutes.
Sequential infusion codes are used when drugs are administered back-to-back and a sequential code is used once per drug.
Hydration must have a medically necessary reason to be billed in the note and should not be billed only to administer drugs or other substances. As a time-based code, at least 31 minutes must be documented in the record for the service to be billable. This is also the case when hydration is the only service provided.
Lastly, I’ll review any documentation to determine if it is medically necessary for an E/M service if one has been billed. When the patient has a specific order for a chemotherapy regimen across multiple visits, it is not typically necessary for a physician face-to-face billable visit to take place,
When reviewing the provider’s note, the services most likely to be billable will involve management of complications caused by the regimen, and changes to the regimen due to patient tolerance or non-responsiveness to treatment. Complications or other conditions requiring management will justify a separate E/M visit.
The provider may also visit with the patient to manage their overall care at certain intervals through treatment. These visits may or may not be adjacent to infusions and injections. I would recommend being thoughtful about a timeline for these visits that factors in overall responsiveness to treatment and health.
A patient at high risk in poor health will require more intervention than a patient who is responding well to treatment. We look carefully to the documentation to support this and we discount documentation carried forward from visit to visit without change.
