Are You Billing Your Infusions Correctly?

November 02, 2010

The following summary of a CMS notice was published on the TrailBlazer Web site.

Drugs and Biologicals: Billing and Documentation Error Prevention

Drugs and biologicals have gained increased attention due to errors identified within medical record documentation and with billing. As a result, we are providing information on the most common errors, and education on how your practice can avoid them. The top errors include: 

1. Units Billed Conflict with the Amount Administered
Providers should confirm the dosage administered is consistent with the units billed. To ensure accuracy, observe the dose per unit (according to the Health Care Common Procedure Coding System (HCPCS) code) and documentation of the dose administered. When the dosage amount is greater than the amount indicated for the HCPCS code, round up to determine the number of units to bill. When the dosage amount is less than the amount indicated for the HCPCS code, use one as the unit of measure.

Two examples on how to calculate the number of units using the dosage administered are provided below.

Example 1

HCPCS

Drug

Dosage

J1030

Methylprednisolone

40 mg

Scenario
Your patient presents with complaints of pain in the right knee. The decision is made, after evaluation, to inject methylprednisolone into the affected knee. Methylprednisolone, 80 mg, is administered.

Correct Calculation of Units
According to the HCPCS book, the dose per unit for J1030 is 40 mg. It would be appropriate to bill two units for the above scenario (80 mg/40 mg = two units).

Example 2

HCPCS

Drug

Dosage

J1200

Diphenhydramine

50 mg

Scenario
Your patient presents with complaints of swelling, redness and itching after a dose of a new antibiotic. An evaluation reveals the patient is having an allergic reaction to the antibiotic. The decision is made to inject diphenhydramine, 25 mg, and it is administered.

Correct Calculation of Units
According to the HCPCS book, the dose per unit for J1200 is up to 50 mg. It would be appropriate to bill one unit.

2. Infusion Administration Times
Billing infusion codes can sometimes become confusing, especially if the infusion times are not accurately documented. The easiest portion of billing drug infusion codes is billing for the “initial” code. Often, errors are identified when only the add-on code is utilized. Below are a few tips to help:

  • Bill infusion codes based on the actual time of administration of the drug:
    • The administration begins when the actual drug starts, not upon the insertion of the intravenous catheter or when the normal saline (NS) solution begins to infuse.
    • The administration ends when either the provider stops the drug or the infusion of the drug is completed.
  • The records should reflect the specific start and stop times of the drug administration.

An example of appropriate billing of infusion codes is provided below.

Scenario
Your patient comes to the office to receive a drug infusion. The chart below documents the administration times found within the documentation.

Description

Time

IV started

9 a.m.

NS infusing

9:01 a.m.

Drug started

9:20 a.m.

Drug stopped

11:05 a.m.

IV discontinued

11:07 a.m.

Actual administration time: 1 hour, 45 minutes.

Which administration codes are appropriate based on the previous information?

  • The physician would report the “initial” code up to one hour and the add-on code for the additional 45 minutes.
  • The record needs to clearly reflect the actual infusion time of the drug. Do not include time spent on IV insertion, NS infusion or when the IV was discontinued when calculating the drug infusion time.
  • Billing the additional add-on code for “each additional hour” is not appropriate unless the infusion interval is longer than 30 minutes beyond the one-hour increment.

3. Drug Wastage
Accurately documenting any amount of drug wastage in the record is essential, regardless of use of the JW modifier when billing for the drug/biological.

Documentation of drug wastage should include: 

  • Date and time.
  • Amount of drug wasted.
  • Reason for wastage.

Medicare provides payment for the discarded drug/biological remaining in a single-use drug product after administering what is reasonable and necessary for the patient’s condition. Billing for drug wastage has several specific guidelines that must be followed. For more information, including those specific guidelines and clinical examples, review the drug wastage job aid.

4. Billing E/M Codes with Drug Administration
TrailBlazer has identified, through medical review, incorrect billing of E/M codes when there is not a significant separately identifiable service from the preparation/administration of the injection/infusion of the billed drug. Medicare does not reimburse E/M services when the only service rendered involves drug preparation/administration.

To bill an E/M service with drug administration, the patient should have a separately identifiable problem that warrants the E/M service, above and beyond the procedure itself. Routinely billing E/M services with drug administration is not an acceptable practice unless documentation clearly indicates the patient needed E/M by the physician for a new or exacerbated condition. Billing for this E/M service would entail more than the work typically performed before and after an infusion. When seeing a patient for a separately identifiable problem, bill the appropriate E/M code with the 25 modifier.

Scenario
Your patient comes in to the clinic for her weekly drug infusion. While the nurse is speaking to the patient, the patient reveals that her blood pressure has been elevated. The physician then evaluates the patient and makes drug dosage changes.

Correct Use of Modifier 25
Reporting the 25 modifier with the appropriate level of E/M code in addition to the drug administration is appropriate. The E/M service was medically necessary and a separate, significant service was performed on the same day as the drug administration.

For more information on billing E/M codes with the 25 modifier, see the E/M services manual.

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