The Current Procedural Terminology (CPT) guidelines contain detailed information and direction for the appropriate code application of Intravenous Injections and Infusions.
Billing Requirements
Providers must follow CPT guidelines when coding infusions and injections. Infusion and Injection services are not intended to be reported by the physician or Qualified Healthcare Practitioner (QHP) in the facility setting. Instead, physicians should select the most appropriate Evaluation and Management (E/M) service. When an E/M service is performed in addition to the infusion or injection service, modifier -25 must be appended to the E/M service to indicate that the service provided was significant and separately identifiable.
The injection and infusion billing requirements are determined based on if the services are reported by either a physician/QHP or a facility. Both the physician/QHP or facility may only report one initial service code unless the protocol or patient condition requires that two separate intravenous (IV) sites must be utilized. The difference in time and effort in providing this second IV site access may be reported using the initial service code and appending an appropriate modifier.
- Physicians/QHPs – Report as infusion or injection based on the physician’s/QHP’s knowledge of the clinical condition(s) and treatment(s)
- Facilities – Report based on CPT hierarchy rules:
- Chemotherapy services are primary to Therapeutic, Prophylactic and Diagnostic services
- Therapeutic, Prophylactic and Diagnostic services are primary to hydration. The order is:
- Chemotherapy
- Therapeutic, prophylactic, and diagnostic services
- Hydration
- Infusions are primary to IV pushes, which are primary to injections. The order is:
- Infusions
- IV push
- Injection
Chemotherapy Administration
Providers may only bill Chemotherapy Administration codes (96401-96549) for the following as these require additional physician or other QHP work and/or clinical staff monitoring above therapeutic drug administration codes (96360-96379):
- Parenteral administration of non-radionuclide anti-neoplastic drugs
- Administration of anti-neoplastic agents provided for treatment of non-cancer diagnoses (e.g., cyclophosphamide for auto-immune conditions)
- Administration of monoclonal antibody agents
- Administration of other biologic agents
Providers should not report Chemotherapy Administration codes for:
- Administration of anti-anemia drugs
- Administration of anti-emetic drugs
Infusion Start / Stop Time
Infusions may be concurrent (i.e., multiple drugs are infused simultaneously through the same line) or sequential (infusion of drugs one after another through the same access site). Selection of the correct CPT code is dependent upon the start and stop time of infusion services. If “stop time” is not documented, only an IV push can be billed. An IV infusion differs from an IV push. An IV push is defined as an infusion lasting 15 minutes or less. Therefore, it is important to use the following guidance:
- Infusion services are coded based on the length of the infusion, which is a time-based service.
– 15 minutes or less - Infusions lasting 15 minutes or less would be coded as an IV push
– 16 minutes or more – Infusion codes can be reported after 16 minutes.
- The Start and Stop times of each medication administration must be accurately recorded, as this determines the correct CPT code assignment.
- The first hour of infusion is weighted heavier than subsequent hours to include preparation time, patient education, and patient assessment prior to and after the infusion.
- The time calculations for the length of the infusion should stop when the infusion is discontinued and restart at the time the infusion resumes.
Hydration Infusions
Hydration Infusion Codes 96360 and 96361 are intended to report IV hydration infusion to consist of a pre-packaged fluid and electrolytes (eg, normal saline, D5-1/2 normal saline + 30 meq KCL/liter) but are not used to report infusion of drugs or other substances.
- Report IV Hydration infusion using:
- CPT 96360 – An intravenous infusion of hydration of 30 minutes or less is not billable
- Hydration infusion must be at least 31 minutes in length to bill the service
- It is appropriate to charge for hydration provided before and/or after therapeutic infusion
- Hydration time intervals should be continuous and not added together
- Saline solution is a hydration service and can be reported if electrolytes are added to solution
- CPT 96361 – Use this add on code once infusion lasts 91 minutes in length
- Do not report IV Hydration:
- If a separate bag of fluid is hung and run concurrently with another drug or therapeutic infusion
- If hydration is not continuous for at least 31 minutes
- If electrolytes are administered in a bag minus saline as this is considered a drug
- If there is no stop time documented, then the hydration service is not chargeable
Service Included in Infusion
- Use of local anesthesia
- IV access
- Access to indwelling IV subcutaneous catheter or port
- Flush at conclusion of infusion
- Standard tubing, syringes, and supplies
- Preparation of chemotherapy agent(s)
IV Push Start / Stop Time
An IV Push is defined as an injection which the individual who is administering the drug/substance is continuously present during the administration or an IV Infusion less than 15 minutes. An IV Push exceeding 15 minutes does not constitute billing an infusion code. Providers may report an additional IV push of same drug/substance when the subsequent push is at least 31 minutes after the initial IV Push. Providers may not report the subsequent push if it is within 30 minutes of the prior IV push for the same drug/substance.
Limitations & Exclusions
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, payment integrity edits, and medical necessity
- Mandated or legislative required criteria will always supersede.
In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.
Cross References
- Current version of AMA CPT Manual CPT® is copyright American Medical Association. All rights Reserved. The AMA assumes no liability for the data contained in this policy.
- Social Security Administration, Section 1861(t); Part E. Social Security Act §1861 (ssa.gov)
History
Date
|
Updates
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5/18/2022
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Created Injection and Infusion coding and billing guidelines. |
8/26/2022
|
Policy reviewed and changed CPT code from 99401 to 96401. |
8/14/2023
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Completed yearly review. Added payment integrity edit within limitation and exclusion statement. |
