Microsoft word - drug administration guidelines sept 09.doc

UCLA Health System Office of Compliance and Privacy Disclaimer:
Please be advised that this guideline is a compilation of information from various sources as enumerated in the reference section. While every effort has been made to ensure the accuracy of the information provided according to the most current CMS transmittals, CPT Coding Manual, CPT Changes, and CPT Assistant advices pertaining to the subject, periodic change to rules and coverage may occur. ICD-9-CM diagnosis codes are updated on the 1st of October and HCPCS codes on the 1st of January annually. DRUG ADMINISTRATION GUIDELINES
For Calendar Year 2009

CMS DRUG ADMINISTRATION INSTRUCTIONS:
(Medicare Claims Processing Manual)
Hospitals are instructed to:
• Use full set of drug administration CPT codes, including those codes referencing concepts of initial, concurrent, and sequential, to bill for drug administration services furnished in the Hospital Outpatient Department. • Continue to use C8957, Intravenous infusion for therapy/diagnosis; initiation of prolonged infusion (more than 8 hours), requiring the use of portable or implantable • Report all drug administration CPT codes in a manner consistent with: 2. CPT instructions, and
3. Correct coding principles
• Hospitals should report all HCPCS codes that describe the drug administration services provided, regardless of whether or not those services are separately paid or • Hospitals are to bill a separate Evaluation and Management code (with modifier -25) only if a significant, separately identifiable E/M service is performed in the same
encounter with OPPS drug administration services.

APC PAYMENT FOR DRUG ADMINISTRATION SERVICES:
CY 2007, OPPS drug administration APCs were restructured to provide a separate APC
payment for each reported unit of a separately payable HCPCS code.
• Beginning in CY, 2007 the 1st hour concept no longer exists. CPT codes in CY 2007 and beyond allow for only 1 initial service per encounter, for each vascular
access site, no matter how many types of infusion services are provided, with
other services through the same vascular access site being reported via the
sequential, concurrent, or additional hours codes.
Hospitals will receive an APC payment :
2. Separate APC payment(s) for additional hours of infusion or other drug administration services provided that are separately payable. For APC payment rates, refer to the most current quarterly version of Addendum B on the CMS Web site at http://www.cms.hhs.gov/HospitalOutpatientPPS/. Updated:
September 2009 January 2009 February 2008 2/13/07 01/17/07 IR UCLA Health System Office of Compliance and Privacy DEFINITIONS AND REPORTING INSTRUCTIONS:
INITIAL SERVICE
• Initial service code is reported only 1 time per encounter and the subsequent, sequential, and concurrent codes are reported regardless of the subsection in which • When administering multiple infusions, injections or combinations, only 1 “initial” service code should be reported, unless protocol requires that 2 separate IV sites must be utilized • To report 2 different “initial” service codes use Modifier -59. • For Hospital reporting, the initial code is determined based upon the hierarchy of drug • For Physician reporting, the initial code that best describes the key or primary reason for the encounter should always be reported regardless of the order in which the Medicare Billing Instructions:
• Drug administration services are to be reported with a line item date of services on
Initial Service in Observation Services:
• One initial drug administration service is to be reported per vascular access site per encounter, including during an encounter where observations services span more
CONCURRENT INFUSION:
• Concurrent Infusion is the service in which multiple infusions are provided
simultaneously through the same venous access site, or when two distinct infusions are given in two separate lumens in a multilumen catheter IV site. • Concurrent infusion code is reported only once per encounter. • In order to report a concurrent administration, the drugs cannot simply be mixed in 1 bag; there must be more than 1 bag. Multiple drugs mixed in one bag are considered one infusion and are not reported as concurrent infusion. • If the drugs are being infused at the same time in 2 different bags, then an initial infusion code and the concurrent code should be reported Example:
A 64-year-old patient simultaneously receives two antibiotics mixed in different bags over the course of one hour. Admixture requirements call for the antibiotics to be administered in separate bags of solution. He becomes nauseated and receives an IV push over 5 minutes of an anti-emetic. The following services should be reported: Initial service: intravenous infusion of an antibiotic (neither hydration nor Concurrent infusion of simultaneous antibiotics Sequential IV push of anti-emetic. Updated:
September 2009 January 2009 February 2008 2/13/07 01/17/07 IR UCLA Health System Office of Compliance and Privacy SEQUENTIAL INFUSION:
• Sequential Infusion is considered to be an infusion occurring one after the other.

Note: Sequential intravenous push of the same drug must be at least 30 minutes apart
INTRAVENOUS OR INTRA-ARTERIAL PUSH:

Intravenous or Intra-arterial Push is defined as:
• an injection in which the health care professional who administers the substance/drug is continuously present to administer the injection and observe the patient, or
INJECTIONS:

Injections, delivers a dosage in one “shot,” rather than over a period of time.
• Subcutaneous injections are commonly administered in the upper arm, thigh,
back, or buttock. Subcutaneous injections are given when immediate action of the substance being injected is required, or when a substance may not be administered • Intra-muscular injections are commonly administered in muscles located in the
upper arm, buttock, hip, or thigh. When a drug may irritate the skin or a large quantity of a long-lasting drug is needed, the intramuscular route of administration • Intra-arterial injection describes an injection that is delivered into an artery.
• Intra-venous injection describes an injection that is delivered into a vein

PACKAGED SERVICES:
• If performed to facilitate the infusion or injection, the following services are included 3. Access to indwelling IV, subcutaneous catheter or port 5. Standard tubing, syringes and supplies 6. Preparation of the chemotherapy agent(s)
HIERARCHY FOR SELECTING THE INITIAL CODE:
HOSPITAL REPORTING:
For Facility reporting, the “initial” code should be selected using the following hierarchy:
4. Therapeutic, prophylactic, & diagnostic infusions 5. Therapeutic, prophylactic, & diagnostic push technique 6. Therapeutic, prophylactic, & diagnostic injections Updated:
September 2009 January 2009 February 2008 2/13/07 01/17/07 IR UCLA Health System Office of Compliance and Privacy PHYSICIAN REPORTING:
• The initial code that best describes the key or primary reason for the encounter should always be reported regardless of the order in which the infusions or injections occur.
DOCUMENTATION:
In order to appropriately bill for infusion services the Physician and Nurses must document:
• Drug administration services require an order from the physician. • Reason for the service to ensure medical necessity ● START and STOP time of drug /substance


INFUSION TIME
• The infusion time is defined as the actual time over which the infusion is administered. Infusion time is calculated from the time the administration commences (i.e., the infusion starts dripping) to when it ends (i.e., the infusion stops dripping). • Intravenous or intra-arterial push administration are differentiated from the other infusion services and defined as “an infusion of 15 minutes or less.”
ACTUAL TIME COUNT:
FIRST (initial) HOUR:
Initial or first hour is from 16 minutes to 90 minutes.
ADDITIONAL HOURS:
The additional hour (s), after the 1st hour, of sequential infusion as well as the second and subsequent hours for infusion services can be reported if the
intervals are greater than 30 minutes beyond 1 hour increments.

Examples:

90 minutes = 1 unit of the first (initial) hour code 91 (1hour, 31 mins.) minutes = 1 unit of 1st (initial) hour code + 1 unit of each Additional hour code 2 hours and 30 mins. = 1 unit of 1st (initial) hour code + 1 unit of each additional hour code. 2 hrs, 31 minutes to 3 hours, 30 minutes = 1 unit of 1st (initial) hour code + 2 units
of each additional hour code.
DRUG ADMINISTRATION RELATED TO OPERATIVE PROCEDURES:
• Under the OPPS Drug administration services related to operative procedures are included in the associated procedural HCPCS/CPT codes, and are not separately reported. Examples of such drug administration services include, but are not limited to; 1. Anesthesia (local or other),
2. hydration, and
3. medications such as anxiolytics (antianxiety agents) or antibiotics
Updated:
September 2009 January 2009 February 2008 2/13/07 01/17/07 IR UCLA Health System Office of Compliance and Privacy • Medicare Global Surgery Rules prevent separate payment for postoperative pain • If drug administration services are provided for a purpose unrelated to anesthesia, intra-operative care, or post-procedure pain management, the drug administrations service codes may be reported with modifier -59.
INFUSIONS STARTED OUTSIDE THE HOSPITAL:
Hospitals may receive Medicare beneficiaries for outpatient services who are in the process
of receiving infusion at their time of arrival at the hospital. For example, a patient who arrives via ambulance with an ongoing intravenous infusion initiated by paramedics during Hospitals should report all services provided using the HCPCS code(s) that most accurately describe the service(s) they provided. This includes hospitals reporting; 1. Initial hour of infusion, even if the hospital did not initiate the infusion, and
2. additional HCPCS codes for additional or sequential infusion services if

( Medicare Claims Processing Manual, Chapter 4, Sect. 230.2, paragraph D)

E & M SERVICES:
If a significant, separately identifiable Evaluation and Management service is performed, the
appropriate E/M service code should be reported using modifier -25 in addition to 96360-
96549. For same day E/M service, a different diagnosis is not required.

GROUPS OF DRUG ADMINISTRATIONS CODES

I HYDRATION SERVICES
96360-96361

2009 Change:
• The 2008 hydration codes 90760-90761 have been deleted and renumbered as
INTENDED USE:
• Codes 96360-96361 are intended to report hydration IV infusion to consist of :
PRE-PACKAGED FLUID AND ELECTROLYTES, e.g.; D5-1/2 normal saline + 30 mEq KC1/liter • These codes are not to be reported by the physician in the facility setting.
REGULATORY GUIDELINES:

• Hydration codes may not be concurrent but may be sequential.
• Hydration may not be reported if the time is 30 minutes or less. • Subsequent hydration infusion hours must be greater than 30 minutes beyond the 1st Updated:
September 2009 January 2009 February 2008 2/13/07 01/17/07 IR UCLA Health System Office of Compliance and Privacy • The fluid used to administer drug(s) is considered incidental hydration and is not • Hydration performed before or after chemotherapy is separately reportable if patient’s
HYDRATION SERVICES - CLINICAL EXAMPLES:
EXAMPLE 1:
A patient with dehydration was admitted at ER and was infused with hydration fluids for 2 hours.
Hospital will report:
NO. OF
UNITS
Fluids, up to 1 hour +96361 IV Infusion of hydration
EXAMPLE 2:
A patient receives medically necessary hydration to ensure adequate renal blood flow and
minimize nephrotoxicity from 8:00 AM until 10:30 AM; and from 8:00AM until 9:30 AM, cisplatin chemotherapy is administered followed by etoposide from 9:30 AM until 10:30 AM through the same venous access site.
Hospital will report:

NO. OF
UNITS
up to 1 hour +96417 sequential, new drug Rationale:
Because the hydration infusion occurred simultaneously with the chemotherapy infusions,
the hydration infusion is not reported. If the hydration was medically necessary and
performed before or after the chemotherapy, the hydration would be reported separately.
(Ref: CPT Assistant, June 07, pagers 4,5)

II. THERAPEUTIC, PROPHYLACTIC, AND DIAGNOSTIC INJECTIONS AND
INFUSIONS (96365-96379, C8957)

2009 Change:
• The therapeutic, prophylactic, and diagnostic injection and infusion codes 90765- 90779 have been deleted and renumbered as codes 96565-96379. Updated:
September 2009 January 2009 February 2008 2/13/07 01/17/07 IR UCLA Health System Office of Compliance and Privacy
INTENDED USE:
• These codes are used for reporting administration of non-antineoplastic drugs/substances for therapy (e.g., an antibiotic), prophylaxis (e.g., immunoglobulin), or diagnosis (e.g., administration of evocative or suppressive agents). • These codes are not to be reported by the physician in the facility setting.

For Medicare patients: Hospitals are to continue to bill HCPCS code C8957 when
appropriate.

C8957 Intravenous infusion for therapy/diagnosis; initiation of prolonged
infusion (more than 8 hours), requiring use of portable or implantable pump.

THERAPEUTIC, PROPHYLACTIC, AND DIAGNOSTIC INJECTIONS AND INFUSIONS -
CLINICAL EXAMPLES:

Example of hydration fluid (Normal Saline) as vehicle for drug infusion:
Patient was admitted for drug administration. Antibiotic was added to Normal Saline and the
patient was infused with the infusate for 2 hours and 15 minutes.

Hospital will report:
initial to 1 hr. 96366 each additional 1
Example of selection of initial service using hierarchy for facility reporting:
Patient came to ER due to nausea and vomiting. Patient was administered drugs as follows: IV infusion - hydration fluids from 12:00 – 13:00 = 1 hr. IVP of Phenergan at 13:20, and
IVP of Reglan at 13:30

Hospital will report:
+96375 ea. additional 1 Sequential IVP 96361 each additional hr, IV Updated:
September 2009 January 2009 February 2008 2/13/07 01/17/07 IR UCLA Health System Office of Compliance and Privacy Example of concurrent infusion:

Patient was admitted due to infection. Patient was administered therapeutic drugs as
follows;
IV infusion – Drug A: 1000-1100 = 1 hr. IV infusion (2nd bag, same line) – Drug B: 1000-1100 = 1 hr. Hospital will report:
NO. OF
UNITS
Drug B using a different bag administered thru the same IV site at the same time as Drug A was a concurrent infusion of therapeutic drugs.
Example of sequential drug administration:

A patient was administered drugs as follows:
IV infusion – Decadron: 0900-0935 IV infusion – Benadryl: 0945-1020
Hospital will report:
NO. OF
UNITS

Benadryl was administered after the initial infusion of Decadron.
Example of multiple sequential intravenous push of same drug (facility):
A patient with CHF was given a multiple IV push of the same drug as follows:
Hospital will report:
NO. OF
UNITS
IV pushes of the same drug given at 30 minutes interval. Updated:
September 2009 January 2009 February 2008 2/13/07 01/17/07 IR UCLA Health System Office of Compliance and Privacy
Example – Infusion and Multiple IM injection
Patient was admitted for drug administration. The following services were performed: IV infusion – Zometa – 1630-1735 IV access was flushed with: Normal Saline 20cc Hospital will report:
NO. OF
UNITS
Drug, initial, up to 1 hour 96372 IM injection Plushing of catheter at conclusion of infusion is integral to the administration services, and should not be reported separately.

Example of Medicare beneficiary receiving long hours of therapeutic drug infusion:
A 65 year old Medicare patient presents for one of several periodic prolonged intravenous infusions of therapeutic drug in an implanted pump.
Hospital will report:
(more than 8 hrs.), requiring the use of portable or
III. CHEMOTHERAPY ADMINISTRATION
(96401-96549)
INTENDED USE:
Chemotherapy administration codes 96401-96549 apply to parenteral administration of:
• Non-radionuclide anti-neoplastic drugs • Anti-neoplastic agents provided for treatment of non-cancer diagnosis (e.g., cyclosphosphamide for auto-immune conditions
Codes 96401-96402, 96409-96425, 96521-96523 are not intended to be reported
by the physician in the facility setting.

Updated:
September 2009 January 2009 February 2008 2/13/07 01/17/07 IR UCLA Health System Office of Compliance and Privacy Codes 96405, 96406, 96440, 96445, 96450, and 96452 describe services that may
require physician reporting in the facility setting.
(Ref: CPT Changes 2009, CPT Assistant, February 2009, pages 17-21))


CONCURRENT ADMINISTRATION OF CHEMOTHERAPEUTIC DRUGS
Due to evidence of current practice standards, there is no code at this time for concurrent
administration of chemotherapeutic drugs.
• If chemotherapy agents are mixed or given concurrently, report 96549, unlisted

(Ref: CPT Assistant, Feb 2009, pages 17-21)


CHEMOTHERAPY ADMINISTRATION - CLINICAL EXAMPLES:
Example - Chemotherapy with sequential hydration fluid and anti-emetic:
Patient was admitted for chemotherapy, the following drugs were administered:
IVPB 5-FU (chemotherapy) – 1015-1130 = 1 hr., 15 mins. IVPB – Zofran (therapeutic) – 1140-1225 = 45 mins. Hydration fluids – 1230-1330 = 1 hr.
Hospital will report:
Up to 1 hour +96367 additional sequential Infusion, therapeutic drug up to 1 hour +96361 each additional hr, IV Chemotherapy is reported as initial code consistent to guidelines: 1. Chemotherapy is primary reason for the encounter. 2. Chemotherapy administration hierarchy is primary to therapeutic and hydration CPT code 96361 for hydration is reported since it was given as a subsequent infusion after the chemotherapy.

Updated:
September 2009 January 2009 February 2008 2/13/07 01/17/07 IR UCLA Health System Office of Compliance and Privacy Example – Chemotherapy with additional infusion hours and sequential therapeutic
infusion of less than 15 minutes.
Patient was admitted for chemotherapy, the following drugs were administered: IVP – Reglan – 0900-0910 = 10 mins. IV infusion – Decadron – 0910-0920 = 10 mins. IV infusion – Cisplastin (chemo) – 1020-1220 = 2 hrs.
Hospital will report:
NO. OF
UNITS
Infusion, up to 1 hour +96415 each additional hour of Chemotherapy infusion +96375 sequential IVP of non-
Chemotherapy administration hierarchy is primary to therapeutic administration.
IV infusion of Decadron for 10 minutes is reported as IVP.
Example – Sequential and additional infusion hours of chemotherapeutic drugs:
Patient was admitted for chemotherapy, patient was administered 2 chemotherapy drugs sequentially: Chemotherapy Drug A – 2 hours Drug B – 4 hours

Hospital will report:
NO. OF
UNITS
Infusion, up to 1 hour +96415 each additional hour of Chemotherapy infusion +96417 each sequential chemotherapy Infusion, up to 1 hour +96415 each additional hour of

Updated:
September 2009 January 2009 February 2008 2/13/07 01/17/07 IR UCLA Health System Office of Compliance and Privacy

Example - Chemotherapy with pre and post chemo hydration infusion
Patient with ovarian carcinoma was admitted for chemotherapy. The physician ordered a pre
and post chemotherapy hydration to support patient’s volume status. The following substance/drugs were administered: IV infusion – D5W/0.45%NaCl + KCl 10mEq/L – 1300-1455 = 1 hr, 55 mins. 1645-1745 = 1 hr. IV infusion - Diphenhydramine – 1500-1515 = 15 mins.
IV infusion – Topotecan (Chemotherapy) – 1520-1630 = 1hr, 10 mins.
Hospital will report:
Up to 1 hour +96375 each additional sequential IVP of a new drug +96361 each additional hour of IV Codes are listed consistent with administration hierarchy rules. IV infusion of Diphenhydramine of 15 minutes is reported as IVP. Pre and post chemotherapy infusion of hydration fluids is separately reported with code 90761 for 3 units. Updated:
September 2009 January 2009 February 2008 2/13/07 01/17/07 IR UCLA Health System Office of Compliance and Privacy References:
CMS, Claims Processing Manual, chapter 4, Part B, Section 230, Revision: 7/30/09
CMS, Transmittal 1702, CR 6416, 3/13/09 CMS, Transmittal 1445, CR 5946, 02/08/08 CMS , Transmittal 1139, CR5438 CPT 2009, Professional Edition CPT 2008, Professional Edition CPT 2007, Professional Edition HCPCS Level II, 2009 HCPCS Level II, 2008 CPT Changes 2006, 2007, 2008, 2009 CPT Assistant, February 2009, Pages: 17-21 http://www.cms.hhs.gov Updated:
September 2009 January 2009 February 2008 2/13/07 01/17/07 IR

Source: http://compliance.uclahealth.org/workfiles/PDFs/Drug_Administration_Guidelines_September_2009.pdf