December 1, 2023 | By Natasha Timberlake, BSHCM, CRCR, CPC, CPB, COC, CRC, CPPM, CPMA, CHONC, AAPC Approved Instructor
Reviewing the rules and guidelines regarding chemotherapy and therapeutic infusions and injections can be intimidating and confusing. Here are some helpful tips to help it become easier to understand.
The first step is to review the MAR (Medication Administration Record). In the context of medical documentation, the MAR is a legal document used in healthcare settings to track the administration of medications to patients. It includes details such as the patient’s name, the name of the prescribed medication, the dosage, the route of administration, the date and time of administration, and the signature of the healthcare professional administering the medication.
When examining the MAR, you will be able to verify whether the medication is therapeutic or chemotherapy. This can be done by checking your facility or provider’s office reference sheet, drugs.com, or the medication manufacturer’s website. After confirming it is chemotherapy, you must determine the specific subcategory. This includes verifying if it is an antineoplastic, monoclonal antibody (immunotherapy), hormonal or non-hormonal. Antineoplastic and monoclonal antibodies (immunotherapy) have additional Z-code diagnosis codes that may be used. Determining hormonal and non-hormonal chemotherapy medication will also assist in applying the correct administration code for subcutaneous and IM injections.
The administration of chemotherapy and therapeutic infusions and injections are based on the medication, not diagnosis codes. For instance, a patient comes in with an active cancer diagnosis but is receiving treatment with nausea and vomiting medication. The administration of the drug would be therapeutic since it is based on the medication. On the other hand, a patient with multiple sclerosis or rheumatoid arthritis may be receiving treatment with methotrexate. This is a chemo medication. So, the administration of the drug would be chemotherapy. That is why it is a good idea to start all coding reviews at the point of the infusion and injections with the MAR (Medication Administration Record) first and the diagnosis coding last, so it isn’t confusing and leads to unintentional mistakes.
Next, you need to review the coding guidelines for infusion and injections. Per the AMA CPT code book, “Coding for chemotherapy and therapeutic injections and infusions is based on a hierarchy. Only one initial service code should be reported unless the patient requires that two separate IV sites must be utilized. If injection or infusion is of a subsequent or concurrent nature, even if it is the first such service within that group of services, then a subsequent or concurrent code from the appropriate section should be reported.”
The hierarchy for infusions and injections is chemotherapy infusion, chemotherapy injection, therapeutic infusion, therapeutic injection, and hydration. What helps me remember is chemotherapy is the harshest chemicals you are putting into your body. It may be doing a great job treating the disease, but unfortunately, it may damage the body. So, it is at the top of the hierarchy triangle. Next is therapeutic, which is in the middle of the triangle. You are putting medication into your body, such as medication to help with bone disease or vitamins. Additional chemicals are added to your body but are not as harmful. The last part of the triangle is hydration. This can be used to hydrate the patient with saline or added to chemotherapy and therapeutic medicine.
When reviewing the MAR, you need to verify if there is a start and stop time. This is very important. The route of the medication should be documented, but to determine if it qualifies for an infusion or injection, you need the start and stop time. For instance, an infusion is 16 minutes or more, and an injection is 15 minutes or less. If there is no stop time, you would follow your facility or physician’s office procedures. Sometimes, this may mean a query, or sometimes, the infusion may be down-coded to an injection since there isn’t a stop time to confirm the exact time administered. Infusions are required to have start and stop times. Injections such as IV push do not need to have a stop time. However, I recommend recording all medications’ start and stop times. Education may be necessary for the physicians, nurses, and coders to document and capture all necessary information and correct coding.
Additionally, if no stop time is documented, you cannot determine if the additional hour add-on code for infusion would qualify to be coded. For instance, CPT code 96415 is the chemotherapy IV infusion for each additional hour, and CPT code 96366 is the therapeutic IV infusion for each additional hour. To qualify for the additional hour, it must be past the halfway mark, which is 1 hour and 31 minutes. If it is less than 1 hour and 31 minutes, then it wouldn’t qualify. Each additional hour may be coded more than once depending on how long the medication was administered. If there isn’t a stop time documented, that could lead to incorrect coding since we cannot confirm if additional codes are needed.
Remember, starting at the beginning leads to success. Once the initial code is determined, everything else is subsequent. For example, a patient is seen for chemotherapy infusion (25 minutes), therapeutic infusion (22 minutes), and therapeutic injection (8 minutes). The MAR has been verified, including the start and stop times. The initial code would be 96413, and the subsequent codes would be 96367 and 96375. Another example is a patient seen for a therapeutic infusion (75 minutes) and a therapeutic injection (13 minutes). The MAR has been verified, including the start and stop times. The initial code would be 96365, and the subsequent code would be 96375. The reason the therapeutic infusion is the initial code is based on the hierarchy; it is next in line after the chemotherapy infusion and chemotherapy injection. Since there is no chemotherapy infusion or injection, the therapeutic infusion would first be considered the initial code.
Honestly, the most challenging part seems to be choosing the initial code based on the medication, administration, and hierarchy. So, if this step takes you time to understand its complexities, don’t get rattled.
Next Steps for Success:
- Need assistance for your practice on an hourly basis? Check out this option by NAMAS.
- Contact us to audit your current chemotherapy or other infusion records to ensure correct coding.
