Medicine codes for both therapeutic and diagnostic services include injections, physical medicine, and rehabilitation services. These are some of the most difficult services to audit and, as a result, some of the most frequently audited in the medicine section of CPT®.
Injections and infusions are often problem areas with high error rates. It is important for an auditor to understand the fundamentals of coding injections and infusions and the documentation that is required for these services. These services require a code for both the administration and the drug supply. Units of measurement for the HCPCS Level II code for the drugs are one of the most common errors found during audits.
The audit process for injections and infusions services
The audit process for injection and infusion services aligns with the process for other types of codes. Review the other chapters of the text, which provide information on the general audit process, including the audit scope, approach, statistical sampling, documentation gathering, and more. Once the general audit process is complete, the audit process specific to injections and infusion services begins.
Tip: The hierarchy regarding infusions and injections is as follows: Infusions, Injections/IV pushes, and hydration. Do not assume infusion time based on the physician order alone! There is always a chance that the infusion time was interrupted for some reason and the orders won’t include IV calibration time.
Tip: If the provider asks the patient to bring their own drug or the pharmacy has delivered the drug to the office for the patient, it is not appropriate to bill the drug to the payer. There has been no expense to the practice for the drug.
Note: Take a look at the following sample infusion documentation and refer to the recommendations in the text for complete injection and infusion documentation. This sample includes all of the elements outlined in the text that are essential to accurate injection and infusion coding and auditing. Note that this documentation indicates the start and stop times for the infusion, the substances given to the patient including the lot numbers for the drug vials, all supplies used during the infusion, the method and site, as well as the patient’s condition during and following the infusion.
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