The Confusion of Infusion Billing

I have been in and around medical billing for over 15 years in various practices and ambulatory healthcare services, and I would never tell anyone that medical billing is a simple or logical process. However, with some practical study and a little experience, anyone can eventually learn the nuances of full-revenue cycle medical billing for most medical services. Having said that, infusion billing continues to frustrate me even after many years of study and experience. I have personally overseen $100+ million of infusion and specialty injection claims, and still I have to be very careful to slow down when explaining the infusion and injection billing hierarchy to new clients or new infusion billers.   INFUSION BILLING IS COMPLICATED I already know this article will generate comments and emails from experienced billing experts about how “easy” infusion billing is and how I have over-exaggerated the difficulty here. Sure, anything is made easier through years of study and experience, but let us not kid ourselves, infusion billing is complex stuff. For the honest and humble few of us out there who still struggle with infusion billing, I have tried my best to put together a straightforward and practical guide in an attempt to reduce some of the confusion around the process.   GETTING STARTED Let me say a few things about this article before we start. Everything I will describe here is based on the Medical Benefit, fee-for-service billing methodology. In no way am I wandering into hospital outpatient (HOPD / OPPS), ambulatory surgery, home infusion, or any other class of trade. For Medicare billing, this conversation falls under Medicare Part B. This guide should apply to provider offices offering in-office infusions and injections as well as stand-alone Infusion Centers billing under the medical benefit for place-of-service 11. I will focus primarily on non-chemotherapeutic treatment billing as that is my area of experience to date. For this first article, we are going to only discuss the Administration/Procedure portion of Infusion and Injection billing. I will attempt to tackle billing medications and NDC billing in another article soon.   IDENTIFYING THE PROCEDURES There are some very specific procedure codes that have been created and updated by the various AMA CPT “powers that be” that are used to describe the different types of infusion/injection services available. Broadly, these procedure codes boil down to 3 categories based on the Route of Administration:

• Intravenous Infusions (IV)
• Intravenous Pushes (IVP)
• Injections (Sub-Q, IM)

When looking at a nurse’s treatment note, the biller must be able to clearly identify these 3 different procedure categories and understand their differences. For reference, we have provided definitions and broader descriptions for each of these procedures here on our webpage: Infusion Center Definitions   CODES, CODES, and CODES If you are like me, sometimes I become overwhelmed when there are too many numbers to keep up with. If you are going to be working in medical billing, you must embrace the madness of all the numbers and codes or you will lose your mind and might flip your desk over in the process. For Infusion Therapy Administration in the Provider Office Setting, here is the code set you will be working with:  

INFUSION BILLING CODES TABLE

CODE TYPE	CODE DESCRIPTION	HIGH LEVEL (CHEMO/COMPLEX)	LOW LEVEL (THERAPUTIC)	HYDRATION
INITIAL	Infusion 1st Hour	96413	96365	96360
	IV Push – 1st Push	96409	96374	–
SECONDARY	Infusion Sequential	96417	96367	–
	IV Push (IVP) Sequential	96411	96375	–
ADDITIONAL	Infusion Add’l Hour	96415	96366	96361
	Injection SQ/IM (Per Injection)	96401	96372	–

  Print, bookmark, laminate, and frame this table as it is the single most helpful tool you can have as an infusion biller for the administration codes and the hierarchy for which they are applied.   WHAT IS THE INFUSION HIERARCHY? What makes infusion billing so complicated is all the hierarchies (Yes, hierarchy is plural on purpose). A hierarchy is basically a system for grouping or ranking one item above the other according to status or authority. Here are the Infusion Billing Hierarchy’s for Medication Type and Route of Administration: Medication Type or Service Level:

1. Chemotherapy / Complex Biologic
2. Therapeutic / Diagnostic substance
3. Hydration

Route of Administration:

1. Intravenous Infusions (IV)
2. Intravenous Pushes (IVP)
3. Injections (Sub-Q, IM)

The hierarchy(ies) is the framework for the infusion billing process, and the administration codes are part of that framework. In addition to knowing the hierarchy, there are a few other rules you will need to understand to put it all together.   INITIAL SERVICE CODE RULE For infusion billing, there is an “Initial Service” rule that says you can have only one initial service code per visit. Looking at the table above, you will see that our initial service codes are 96413, 96365, 96360, 96409 and 96374. With few exceptions, you should only ever use ONE of these codes on any billed visit.   HIGH LEVEL OR LOW LEVEL SERVICE RULE In the Infusion Billing Table, there are columns labeled High level (Chemo/Complex), Low Level (Therapeutic/Diagnostic), and Hydration. You will need to know the level that you can bill for each medication you will encounter on a nurse’s treatment note. Knowing the level for each medication is not always as clear as it should be. Any chemotherapeutic medication is going to be a High Level code without question. Some other medications fall into a gray area that Medicare and some Insurances will consider allowed for High Level codes as well. These typically include biologic/monoclonal antibody products, but not always. The latest Medicare CMS Guidance Found Here (section 30.5) specifically names rituximab (Rituxan), infliximab (Remicade), and alemtuzumab (Lemtrada). Since they did not list any others by name, some insurance companies don’t consider many of the other biologicals as “High Level” medications. You have to look at your local Medicare MAC’s guidance for this information and also at your individual insurance contracts to know for sure. Knowing if the medication is a High Level, Low Level, or Hydration classification is necessary to properly bill the administration part of the treatment.   TIME RULES FOR INFUSION CODES If you looked closely at the Infusion Administration table above, you will see a few references to time on the infusion code descriptions. Infusion billing is mainly about billing for the time a patient is being infused. The total time the patient is physically in the office, infusion chair, bathroom, etc. is totally irrelevant. When billing infusion administration time, we are only ever referring to the time that the medication is dripping into an IV line. No drip, no tick (like a clock…I know it doesn’t rhyme).  Time is always billed by the hour and there is some funny rounding involved. For the first hour, the infusion must be at least 16 minutes (>15mins) to qualify as the first hour of infusion. Anything less gets automatically labeled as an Intravenous Push (IV Push, IVP). For any additional hour, after the initial hour, you can only count the additional hour as billable if the total time is at least 31 minutes into the next hour.   Examples for total billable infusion time as documented:

• 14 minutes, billable only as a single IV Push (<15 minutes)
• 16 minutes, billable for 1 hour of infusion
• 60 minutes, billable for 1 hour of infusion
• 1 hour, 28 minutes, billable for 1 hour of infusion
• 1 hour, 31 minutes, billable for 2 hours of infusion

  HYDRATION / IV FLUIDS I could write an entire article on the nuances of hydration billing. For now, know that hydration or billing for IV Fluids is only possible when the ONLY product being administered is the IV fluids. IV Fluids required for a medication dilution or used for KVO (keep vein open) are considered “incidental fluids” are not separately billable. There are special time rules and some exceptions for IV fluids/hydration billing that we are skipping here for now and I will address later in another article. (Let’s focus on the expensive stuff for now)   HOW TO BILL A TREATMENT FROM THE CLINICAL DOCUMENTATION   Treatment Documentation to use for our Example:

• Benedryl 25mg IVP X 1
• Solu-medrol 1gm IV over 32 minutes
• Remicade 400mg IV over 2 hours and 31 minutes

  STEP 1: Determine the “INITIAL” Service Codes Looking at the nurse’s treatment note documentation, you first need to determine which initial service code is going to be used. As mentioned in our INITIAL SERVICE CODE rule above, you only get to use ONE Initial Code per billed visit. To determine which one, take a look at our Infusion Billing Table. Start with the Route of Administration and determine if you have any intravenous (IV) routes for medications on the documentation. If yes, then determine the level of each of the IV medications listed. If any of the medications are High Level, then the first one administered by the nurse gets the Initial Service Code as shown in the table above. Using our Treatment Note Documentation Example, you can see 3 administered medications – 1 administered with a route of IVP (IV Push), for Benadryl – and 2 administered with a route of Intravenous (IV) for Solu-Medrol and Remicade. Looking at the hierarchy of the Infusion Billing Table, Remicade is the only one that has a Route of IV and is also a High Level medication. For this example, the Initial service (1^st hour) for Remicade would be billed using the 96413 code for 1 unit of service. Remember that we only use one Initial service code per treatment, so once you pick one, leave that top section of the infusion billing table alone for the rest of this treatment note.   STEP 2: Determine any “SECONDARY” Service Codes A good rule of thumb is that each medication gets at least one administration code. At this point, only one of the medications, Remicade in our example, has been assigned an Initial Service Code. The remaining medications are considered “Secondary Services”, and each one gets a code from that section of our Infusion Billing Table. Unlike the Initial Service Codes, the Secondary Service Codes can be used more than once for a treatment, but only once for each secondary medication (I know what you are thinking, who came up with this system?). Once you determine the level and route of each of the remaining medications, you are ready to assign each of them a single secondary service code. Looking at our example, we need to assign a secondary code to 2 of the remaining medications – Benadryl (IVP) and Solu-medrol (IV). Following our Hierarchy Rules and looking at our Infusion Billing Table, we look for any medications with a route of IV first and determine their service level. Next, we look for any medications with a route of IV Push (IVP) and determine their service level. The Solu-medrol is IV and Low Level, so we assign it a single unit for a 96367 code. The Benadryl is IVP and Low Level, so we assign it a single unit for a 96375 code.   STEP 3: Determine any “ADDITIONAL” Codes for all Medications After steps 1, and 2 above, things get a little easier. You should now have at least one service code (either an Initial code or Secondary code) for each of the medications on the nurse’s treatment note, representing the first hour of administration or an IV Push. Now, look at each medication that was administered and use the Time Rule from before to determine how many billable hours (IV route meds only) you have for each medication. Any infusion medication that has additional billable hours beside the first ones (because you already have a code assigned for those in Steps 1 or 2) get Additional Hour codes. Just as before, the code selected depends on the level and route of the medication administered.   Continuing with our example, our levels and billable hours should look like this so far:  

MEDICATION	LEVEL	ROUTE	HOURS/PUSHES	CODE	UNITS
Remicade	High	IV	(2:31) 3 billable hours	96413	1
Solu-Medrol	Low	IV	(32 min) 1 billable hour	96367	1
Benadryl	Low	IVP	1	96375	1

  Total billable hours for Infusions (IV) are Remicade (3) + Solu-Medrol (1) = 4 total billable hours and so far we only have 1+1 = 2 so we still need to capture an additional 2 billable hours. In this case, the Remicade has the additional hours that are unaccounted for. We locate the correct code in our billing table for Additional Service, High Level, and IV. That code is 96415 and we will use 2 units to capture the additional 2 hours of service.   IV Push (IVP) Note For physician-office billing, you are only allowed 1 IVP (IV Push) code per medication. There is no billable “Additional Code” for IV Pushes when the same IVP drug is pushed more than 1 time during the encounter. As with everything in this article, there are exceptions to this rule for advanced study and there is an Additional Code for additional IVP’s used in other settings like the hospital, but for this article, remember that infusions (IV) are the only routes that get Additional Hour codes.   STEP 4: Determine If There Are Any Other Services to Bill There may be other professional services or procedures that were performed during the infusion treatment that are billable, but they don’t have the “Initial” and “Sequential” hierarchy concerns that we have been covering. I won’t go into all the possibilities here, but you should be familiar with all “billable” procedures in your practice and make sure the treatment note documentation is set up to easily label and identify these. The common procedures we need to look for are the Injection codes specifically for Intramuscular (IM) and/or Subcutaneous (Sub-Q, SQ) injections. This billing is much easier. Simply determine if the injections are High or Low level medications and make sure that each injection has a service code and units billed equal to the total number of injections performed.   Example:

• If the treatment note shows 3 SQ injections of a high level medication, then you should select a 96401 code and bill 3 units.
• If you have 2 IM injections of a low level medication, and 1 SQ injection of a high level medication, then you should select a 96372 code for 2 units and a 96401 code for 1 unit.

In the case of our Example Treatment Note, we have been working with, there are no documented IM or SQ injections to bill so we are good.   STEP 5: Review the Billing, Double Check, Triple Check – Then Bill It! I love nurses. They are some of the most compassionate and hardworking people I have ever worked with and they are the backbone of our healthcare delivery system. However, they are not medical billers, and in my personal opinion, we should not put that burden on them. This does not mean that nurses can skip out entirely on their treatment documentation responsibilities. If a nurse puts a medication into a patient’s body, they absolutely must document the Medication, Route, Time, and Dosage of that administration. That responsibility cannot be delegated or avoided if patients are to receive the safe and effective care that the nurse provides. In turn, the Medical Biller has the responsibility to the nurse to thoroughly read all of the treatment note documentation and properly capture all of the hard work that the nurse put into that documentation and treatment. Read it, code it, then read it again. With almost every specialty biological or IVIG medication treatment there are thousands of dollars on the line for the practice and the patient. A lack of thoroughness can bring significant financial harm to your employer and your patients. It is the utmost responsibility of the nurse and the medical biller to treat these expensive medications with the respect they deserve. Now that the point is made, let’s look at our Treatment Note Example again and see what we have determined to bill.  

FINAL INFUSION BILLING CODING

MEDICATION	LEVEL	ROUTE	HOURS/PUSHES	CODE	UNITS
Remicade	High	IV	(2:31) 3 billable hours	96413 96415	1 2
Solu-Medrol	Low	IV	(32 min) 1 billable hour	96367	1
Benadryl	Low	IVP	1	96375	1

  IS IT COMPLICATED? – YES      IS IT ROCKET SURGERY? – NO Like any other learned skill, infusion billing gets easier with practice and experience. Having a solid set of reference tools and the ability to take your time will greatly reduce the learning curve and frustration factor for a “new to infusion” biller.   SOFTWARE AND TECHNOLOGY TOOLS Are there systems in the market that can greatly simplify the infusion billing process? Absolutely, and one of them we happen to build here at WeInfuse. Our WeInfuse software automatically converts our electronic treatment note to a calculated billing output using all of the logic and rules we discussed earlier. The awesomeness of our WeInfuse billing note does not totally excuse the infusion biller from taking the time to understand the infusion billing process and in no way do we recommend that any of our clients use our software as an excuse to check their brains at the door. After all, great tools do their best work best in the hands of experienced and educated students.   CONCLUSION Did I cover every possibility or combination that you could encounter in infusion billing? Absolutely not. Why? Because learning and mastering the basic process that represents the most common treatments for infusion billing should be the first concern. Trying to teach every possible and occasional billing exception is a sure-fire way to confuse and scare off new infusion billers. This is a beginners guide and more advanced study is certainly available for those who are ready to take their infusion billing education to the next level. A great resource for advanced study is Coding Essentials for Infusion & Injection Therapy Services 2018 from MEDLEARN publishing. My hope is that this article has clarified and distilled out some of the confusion of the infusion billing process. In my next installment, we will cover how to bill for the infusion medications themselves. We will look thoroughly at HCPCS/ “J Codes” and the fun, fun world of NDC billing.   WANT TO LEARN MORE ABOUT WEINFUSE? If you would like to learn more about how our WeInfuse software application can help “Take the Confusion out of Infusion” for your in-office infusion suite or standalone infusion center, click here to request a demonstration and let’s start a conversation about how WeInfuse can help you and your team Infuse Better. Disclaimer: This is a guide and is no way intended to be formal billing advice. You must consult your CPT manual and other applicable reference materials.