How to Overcome Challenges in Medicine Auditing

Posted on 10 Jul, 2018 |comments_icon 0|By Elizabeth

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

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.

  • Documentation: The documentation corresponding with the date of service that is being reviewed should be complete. Ensure that the entire note has been read and reviewed.
  • Code First: It is best practice when auditing to code the chart first without considering the codes as they were originally billed.
  • Physician’s Order: The order should provide the name of the drug, dosage, and reason for its administration.
  • Identify the Primary Service: The primary service depends on the location of the service. The primary service for professional services performed in the office setting, is the reason for the encounter. The primary service for a facility service is based on the hierarchy outlined in the CPT® coding manual.

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.

  • Time: The time that each substance was administered also should be included in the documentation to properly select the CPT® code and to sequence multiple drug administrations. CPT® and Medicare do not specifically require start and stop times for drug infusions, but it is good practice to include this information in the documentation.
  • Additional Information: From a best practice perspective, documentation also should include a record that lists the drug source, lot number, and expiration date. The route and the site of each administration also must be documented.
  • Review the Coding: Ensure that the appropriate CPT® codes, ICD-10-CM codes, HCPCS codes and modifiers were billed appropriately. Make sure that all services have been reported and captured. Verify the correct units have been billed with the appropriate HCPCS Level II code.

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.

  • Check NCCI: Check NCCI edits when more than one code has been billed for the same date of service, to determine if unbundling has occurred. Also, check the CPT® manual and guidelines, which provide instructions for coding in the parenthetical notes.
  • Medical Necessity: Ensure medical necessity has been met based on private payer policies and by verifying applicable NCDs and LCDs.

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.

Learn More

Hone your auditing know-how and ensure that your practice doesn’t fall into poor coding, billing, and documentation traps with Master Auditing Basics 2018.



Elizabeth works on an array of projects at TCI, researching and writing about modern reimbursement challenges. Since joining TCI in 2017, she has also covered the nuts and bolts of cybersecurity, compliance with federal laws, and how to tap into the advantages of telehealth services.

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