A: Concurrent infusions should run greater than 16min together. Ref: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=53778
Q: If Alteplase is used prior to a chemo or therapy infusion, for a port/PICC line that is sluggish or not working, can we charge a 36593 for the Alteplase?
A: tPA of the line would be coded separately as thrombolysis using CPT code 36593. This is not the same as a heparin flush of the line, which is considered routine and inclusive of the infusion charge.
Q: How would you code an ED patient received IV meds on 8/4 - Zithromax @ 1243 and Rocephin from 1222 – 1245; on 8/5 Lorazepam @ 1325, Zithromax IV @ 1107, Rocephin 1223 - 1253 and 2237 – 2307?
A: This is considered one encounter. Therefore, the coding should be as follows:
| DOS | Substance | Time | Code |
| 8/4 | Zithromax | 1243 | 96375 |
| 8/4 | Rocephin | 1222-1245 (23 minutes) | 96365 |
| 8/5 | Lorazepam | 1325 | 96375 |
| 8/5 | Zithromax | 1107 | 96376 |
| 8/5 | Rocephin | 1223-1253 (20 minutes) | 96376 |
| 8/5 | Rocephin | 2237-2307 (30 minutes) | 96376 |
Q: Does there have to be medical necessity for a separate IV site to charge a 2nd initial infusion>?
A: It depends on the type of medical necessity and you should follow CMS guidelines for this.
Ref: CPT Assistant, December 2011, Volume 21, Issue 12, page 3 which states that only one initial service code 96365 should be reported. There may be a protocol or patient condition that requires the use of two separate IV sites.
Q: What would medical necessity be for the4 2nd site? What should we look for?
A: Medical necessity is not a black and white issue when it comes to documentation. Sometimes you will see that the patient has tiny veins in one arm, so the other arm is used. Unfortunately, this isn’t something that is always documented. Although the medical necessity for the second site is not always something we can code, documentation should be available in case the payer requests the record.
Q: Can you report an infusion 20 minutes after an IVP of the same med?
A: When an IVP and an IV infusion of the same substance are given within 30 minutes of each other, report only the infusion. Ref: CPT guidelines for Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions, and Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration.
Q: Doesn't a concurrent med have to be in the same site running at the same time?
A: Per CPT Assistant, December 2011, Volume 21, Issue 12, page 3: Concurrent infusions are not time based, and is when a new substance or drug is infused at the same time as another substance or drug. It’s only reported once per day. Keep in mind hydration may not be reported when it is running at the same time as any other service.
Per CPT Assistant February 2009, Volume 19, Issue 2, page 17: CPT 96368 is reported only once per encounter. It’s an add-on code which is reported in addition to the initial infusion code when it’s through the SAME IV access.
Q: What is the difference between modifier 59 and XS modifiers?
A: Modifier 59 indicates a procedure that would normally be a component of another was separately identifiable. The X modifiers (XE, XP, XS, XU) are alternatives to modifier 59 that provide detail about the procedure’s exclusivity, such as a procedure performed in a separate encounter, by a different provider, or at a separate site. The use of modifier 59 vs. the X modifiers is determined by each payer.
Q: If a second IV therapy is given under 31 min, would this be charged as IV therapy additional or IV push?
A: This would code to an IV push. Ref: CPT guidelines for Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions, and Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration.
Q: When will you use the modifier XU for the IV meds?
A: You would not use Modifier XU/59 on the HCPCS codes for drugs. It is rarely used for I&I procedures. An example of when you would use Modifier XU is as follows: A diagnostic procedure is performed. Due to the findings, a decision is then made to perform a therapeutic/surgical procedure. (This may or may not occur in the same procedure room during the same session/encounter.) For example, diagnostic cardiac angiography leads to therapeutic angioplasty.
* See CCI Policy Manual, chapter 1, modifier 59 guidelines. (CMS 2)
* The use of the Z modifiers vs. modifier 59 is payer-specific. If the payer accepts the X modifiers, the appropriate modifier for the situation noted is XU. If the payers do not accept the XU modifier, then modifier 59 is used.
Q: When you have a 96365 and then a hydration 96361 following does that hyration have to meet 31 additional minutes or 91 min before you can assign 96361. IE Zofran 15:00-16:15 and IV hydration 17:00 18:35 - what would codes be (96365, 96361x1 or 96365, 96361x2??)
A: 96365 and 96361 x2. Code 96361 is for each additional hour; anything 31 and over gets rounded up. Since the base code is for a therapeutic substance (96365), hydration is the add-on code and they didn’t run concurrently, so 2 add-on codes for 96361. By times: 15:00-16:15 (1 hour, 15 minutes) for Zofran and then 1700-1835 (1 hour, 35 minutes) for Hydration.
Q: If a provider orders the same IVP drug 20 minutes apart, can we report it?
A: No, they must be 30 minutes apart. Ref: CPT guidelines for Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions, and Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration.
Q: Can hydration be considered a concurrent infusion?
A: No, only infused drugs are considered for this category. Ref: CPT guidelines for Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions, and Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration.
Q: How do we get the correct codes for your scenarios using the 3M Encoder?
A: We recommend using the CPT book or the CPT book function of the 3M encoder when coding these. The codes and guidelines are highly confusing, so this is one area where we always recommend coders rely on book instruction.
Q: For case study #4, I got a different number for subsequent hours of infusion. Could you please verify the number of units for code 96366?
A: The correct coding for this case is
- Day 1: 96365, 96365-XS, 96366x12, and 96361 x2
- Day 2: 96366 x5, 96375, and 96361-2
The breakdown for this coding is as follows:
- Day 1
- IV Clindamycin, right from 11:23-2:23 (3 hours) and 6:00-9:30 (3.5 hours); total reportable hours is 6 (the additional 30 minutes is not reported because the code requires more than 30 minutes [e.g., at least 31 minutes])
- 96365, first hour
- 96366 x5, each additional hour
- IV Doxycycline, left from 11:14-3:14 (4 hours) and 6:15-10:00 (3.75 hours); total reportable hours is 8 (additional 45 minutes is more than 31, so we can round up to an hour)
- 96365-XS, first hour, separate site from other initial
- 96366 x7, each additional hour
- Hydration from 9:00-11:00
- 96361 x2
- IV Clindamycin, right from 11:23-2:23 (3 hours) and 6:00-9:30 (3.5 hours); total reportable hours is 6 (the additional 30 minutes is not reported because the code requires more than 30 minutes [e.g., at least 31 minutes])
- Day 2
- IV Clindamycin, right from 7:08-11:08 (4 hours)
- 96366 x4, each additional hour (initial reported on day 1)
- IV Doxycycline, left from 2:08-3:08 (1 hour)
- 96366, each addition hour (initial reported on day 1)
- IVP of penicillin
- 96375, IVP of new substance
- Hydration from 12:00-2:00
- 96361 x2
- IV Clindamycin, right from 7:08-11:08 (4 hours)
Heather Bertolami, CCS
Senior Coding Quality Auditor
Good morning,
In the instance 2 drugs infusing concurrent and a 3rd drug is starts infused within the same time frame, will only 96365 and 96368 be coded? Or 96365, 96368, and 96367?
Example:
Zofran start time 18:07 – stop time 19:16
Morphine start time 19:02 – stop time19:39
Infuvite Multivitamin start time 19:22 – stop time 20:39
Please help my confusion
Hi Angel,
From the CPT book: “When multiple drugs are administered, report the service(s) and the specific materials or drugs for each.
Also, there is an instructional note in CPT book to “List separately in addition to code for primary procedure.”
Therefore, 96365, 96368, and 96367 is correct.
Hopefully this helps!
Is there a maximum number of units we can charge for cpt 96361?
Hi Julie, The MUE (medically unlikely edit) for 4th quarter 2022 for code 96361 is 24. If they have more than 24 units of the MUE, they should refer to payer policy regarding billing for units of service in excess of the MUE.
My question is which modifier would be appended in the following situation: Per physician orders, a Medicare patient presents at facility Op Infusion unit at 8:00 a.m. and receives an IV Push of antibiotic. Patient leaves facility and returns at 4:00 p.m. for another IV Push of the same antibiotic, (same physician order). CPT code 96374 is assigned x2, one for each separate encounter. What modifier should be appended? The MUE for 96374 is “1” with an MAI of “1”. We are unsure if -76 or -59 is most appropriate. Or do you recommend a different CPT assignment?
Correction to my comment of 3/17/22 a 9:22 p.m. – CPT 96374 -MAI is “3”.
Hello,
This is a very useful article to learn some examples of I&I. I do have 2 questions regarding the table of I&I codes that you have broken down to explain the case example. Firstly, since this is an ED case (Facility), shouldn’t t we code according to the hierarchy? In that case I am assuming the IV infusions, Rocephin should be coded first and then the codes for the IVP’s? Secondly, on day 2 (8/5), the codes for the Rocephin should have been 96366 X2 instead of 96376 X2 and the number of minutes for the Rocephin infusion from 12:23- 12:53 should have been 30 minutes and not 20 minutes. A clarification would be truly appreciated. Thanks!
Hi Roopa –
Thank you for your question! In this case study example #1 from “Tips & Expertise: Injections & Infusions Beyond the Basics Webinar”, the drugs are chemotherapy based, therefore, the codes are correct from the 96413+ section of the CPT code book. We do not have any code examples using Rocephin.