Tuesday, February 28, 2017

cpt 96360, 96361, 93365 - 96372, 96376 - hydration therapy

CPT/HCPCS Codes

Group 1 Paragraph: N/A

Group 1 Codes:

96360 Intravenous infusion, hydration; initial, 31 minutes to 1 hour

96361 Intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure)

96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour

96366  Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure)

96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour (List separately in addition to code for primary procedure)

96368 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure)

96369 Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to 1 hour, including pump set-up and establishment of subcutaneous infusion site(s)

96370 Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure)

96371 Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); additional pump set-up with establishment of new subcutaneous infusion site(s) (List separately in addition to code for primary procedure)

96372 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular

96373 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intraarterial

96374 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug

96375 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure)

96376 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility (List separately in addition to code for primary procedure)

96377 Application of on-body injector (includes cannula insertion) for timed subcutaneous injection

96379 Unlisted therapeutic, prophylactic or diagnostic intravenous or intra-arterial injection or infusion



Coverage Indications, Limitations, and/or Medical Necessity



Indications

The clinical manifestations of dehydration or volume depletion are related to the volume and rate of fluid loss, the nature of the fluid that is lost, and the responsiveness of the vasculature to volume reduction. Rehydration with fluids containing sodium as the principal solute preferentially expands the extracellular fluid volume; a 1-liter infusion of normal saline may expand blood volume by about 300 ml. In general, an imbalance of less than 500 ml of volume is not likely to require intravenous rehydration.

Hydration services are indicated:

In documented volume depletion.

When performed in conjunction with chemotherapy, these CPT codes are covered only when infusion is prolonged and done sequentially [done hour(s) before and/or after administration of chemotherapy], and when the volume status of a patient is compromised or will be compromised by side effects of chemotherapy or an illness.

In some endocrine conditions with findings such as hypercalcemia, prolonged hydration can be medically necessary.

As an adjunct to the treatment of hypotension.
Limitations

Rehydration with the administration of an amount of fluid equal to or less than 500 ml is not reasonable and necessary.

These CPT codes are not to be used for routine IV drug injections.

Hanging of D5W or other fluid just prior to administration of chemotherapy is not hydration therapy and should not be billed with these codes.

When the sole purpose of fluid administration is to maintain patency of the access device, these infusion CPT codes should not be billed as hydration therapy.

Administration of fluid in the course of transfusions to maintain line patency or between units of blood product is not to be separately billed as hydration therapy.

Fluid used to administer drug(s) is incidental hydration and is not separately payable.

Rehydration via hydration therapy of extensively dehydrated patients can be accomplished in hours; therefore, the medical necessity of hydration beyond 12 hours must be documented in the medical record.

These CPT codes require the direct supervision of the physician or non-physician practitioner for the initiation of the service.


Infusion Services

CHEMO THERAPEUTIC HYDRATION INITIAL 96413 96365 96360 Each Additional Hour +96415 +96366 +96361 Subsequent +96417 +96367 Concurrent +96368 Push Initial 96409 96374 Subsequent Push New +96411 +96375 Subsequent Push Same +96376 (Facility only – 30 m

Hydration Intravenous Infusion

• 96360-Intravenous infusion, hydration; initial, 31 i t t 1h 28 minutes to 1 hour
• 96361- Intravenous infusion, hydration; each additional hour

Example # 3

Chose the initial code based on the reason for the encounter. Answer: 34
• Non-chemo IV push = 96375 (each additional)
• 2 hours hydration infusion = 96360 x1 (initial) and 96361 x 1 (each additional)

Blood Draws, Phlebotomy and Port Flushes Phlebotomy

• Services necessary to perform the phlebotomy (CPT codes 36000, 36410, 96360-96376) are included in the procedure 49 the procedure.
– 36000-IV start
– 36410-Venipuncture, age 3 years or older, necessitating physician’s skill, for diagnostic or therapeutic purposes (not to be used for routine venipuncture)
– 96360-96376-Hydration infusions and Therapeutic, prophylactic and diagnostic injections and infusions

E/M Service Performed the Same Day as an Infusion Service The exception to this is CPT code 99211 (level one established patient visit) 55 The drug and chemotherapy administration CPT codes 96360-96375 and 96401-96425 include the work and practice expenses of CPT code 99211

Hydration Infusion Clarification Both the “initial” and “each additional hour” hydration codes require more than 30 minutes of infusion time be documented in order to bill services. If time is less then 31 minutes-no 60 service is reported.

• 96360-initial, 31 minutes to one hour hydration infusion
• 96361- each additional hour, (31 minutes to one hour) hydration infusion



Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
N/A



Policy from OXford insurance



This Oxford reimbursement policy is aligned with the American Medical Association (AMA) Current Procedural Terminology (CPT®) and Centers for Medicare and Medicaid Services (CMS) guidelines. This policy describes reimbursement for therapeutic and diagnostic Injection services (CPT codes 96372-96379) when reported with evaluation and management (E/M) services. This policy also describes reimbursement for Healthcare Common Procedure Coding System (HCPCS) supplies and/or drug codes when reported with Injection and Infusion services (CPT codes 96360-96549 and HCPCS code G0498). For the purpose of this policy, same individual physician, hospital, ambulatory surgical center or other health care professional is the same individual, hospital, ambulatory surgical center or other health care professional rendering health care services reporting the same Federal Tax Identification number.

Exceptions

CPT 99211: E/M service code 99211 will not be reimbursed when submitted with a diagnostic or therapeutic Injection code, with or without modifier 25. This very low service level code does not meet the requirement for "significant" as defined by CPT, and therefore should not be submitted in addition to the procedure code for the injection. CPT 99381-99429: The Preventive Medicine codes (99381-99429) do not need modifier 25 to indicate a significant, separately identifiable service when reported in addition to the diagnostic and therapeutic injection service. The Preventive Medicine codes include routine services such as the ordering of immunizations or diagnostic procedures. The performance of these services is to be reported in addition to the Preventive Medicine E/M code. Therefore, diagnostic and therapeutic Injections can be reported at the same time as a Preventive Medicine code without appending modifier 25.


Injection and Infusion Services (96360-96549 and G0498) and HCPCS Supplies Consistent with CPT guidelines, HCPCS codes identified by code description as standard tubing, syringes, and supplies are considered included when reported with Injection and Infusion services (CPT codes 96360-96549 and HCPCS code G0498) and will not be separately reimbursed.

Drug Codes

Oxford reimbursement policy is aligned with CMS and will separately reimburse for the HCPCS drug code when submitted with Injection or Infusion codes (CPT codes 96360-96549 and HCPCS code G0498) by the Same Individual Physician or Other Health Care Professional on the same date of service under the guidelines of this policy.

APPLICABLE CODES

The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this policy does not imply that the service described by the code is a covered or noncovered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies may apply.

CPT Code Description

96360 Intravenous infusion, hydration; initial, 31 minutes to 1 hour 96361 Intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure)

96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure)

96367 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour (List separately in addition to code for primary procedure)

96368 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure)

96369 Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to 1 hour, including pump set-up and establishment of subcutaneous infusion site(s)

96370 Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure)

96371 Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); additional pump set-up with establishment of new subcutaneous infusion site(s) (List separately in addition to code for primary procedure)

96372 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular

96373 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intraarterial

96374 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug

96375 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure)

96376 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility (List separately in addition to code for primary procedure)




REIMBURSEMENT GUIDELINES

Injections (96372-96379) and Evaluation and Management Services by Place of Service Facility, Emergency Room, and Ambulatory Surgical Center Services Per CPT and the CMS National Correct Coding Initiative (NCCI) Policy Manual, CPT codes 96372-96379 are not intended to be reported by the physician in the facility setting. Thus, when an E/M service and a therapeutic and diagnostic injection service are submitted with CMS Place of Service (POS) codes 19, 21, 22, 23, 24, 26, 51, 52, and 61 for the same patient by the Same Individual Physician or Other Health Care Professional on the same date of service, only the E/M service will be reimbursed and the therapeutic and diagnostic Injection(s) are not separately reimbursed, regardless of whether a modifier is reported with the injection(s).

For additional information, refer to the Questions and Answers section, Q&A1.

Non-Facility Injection Services


E/M services provided in a non-facility setting are considered an inherent component for providing an injection service. CPT indicates these services typically require direct supervision for any or all purposes of patient assessment, provision of consent, safety oversight, and intra-service supervision of staff. When a diagnostic and therapeutic Injection procedure is performed in a POS other than 19, 21, 22, 23, 24, 26, 51, 52, and 61 and an E/M service is provided on the same date of service, by the Same Individual Physician or Other Health Care Professional only the appropriate therapeutic and diagnostic injection(s) will be reimbursed and the EM service is not separately reimbursed. If a significant, separately identifiable EM service is performed unrelated to the physician work (injection preparation and disposal, patient assessment, provision of consent, safety oversight, supervision of staff, etc.) required for the injection service, modifier 25 may be reported for the E/M service in addition to 96372-96379. If the E/M service does not meet the requirement for a significant separately identifiable service, then modifier 25 would not be reported and a separate E/M service would not be reimbursed.



DEFINITIONS

Infusion: A controlled method of administering a substance (drugs, fluids, nutrients, etc) continuously over an extended period of time.

Injection: Insertion of a drug, substance, or solution into the body part (ex: subcutaneous tissue, muscle, vascular tree, or an organ).

Modifier 25 - Significant, Separately Identifiable Service: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding the modifier 25 to the appropriate level of E/M service. (Per Current Procedural Terminology book) Same Individual Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional: The same individual physician, hospital, ambulatory surgical center or other health care professional rendering health care services reporting the same Federal Tax Identification number.



Q: If a HCPCS drug code is submitted in addition to the injection or infusion codes (CPT codes 96360- 96549 and HCPCS code G0498) in a non-facility setting and no other service is performed on the same date of service, will Oxford separately reimburse for both of these?


A: Yes, Oxford would reimburse for both the HCPCS drug code and the Injection or Infusion code (CPT codes 96360-96549 and HCPCS code G0498) under the guidelines of this policy.

Q: Will Oxford reimburse the same physician for both an injection (96372-96379) and an Evaluation and Management (E/M) service code on the same date of service if each is performed in a different place of service*

A: Yes, Oxford will separately reimburse the same physician for both an injection procedure and E/M service on the same date of service if each is performed in a different place of service (POS) and the injection was provided in a POS other than 19, 21, 22, 23, 24, 26, 51, 52, and 61. For example, if the patient only receives an injection at a physician’s office (POS 11) and later that day the patient is admitted to the hospital (POS 21), both services, the injection service performed at the physician’s office and the E/M performed later that day at the hospital, would be separately reimbursed because the injection service and E/M service were performed in different locations by the same physician on the same date of service. Injection services are not reimbursable when provided in POS 19, 21, 22, 23, 24, 26, 51, 52, and 61.


Q: If a Preventive Medicine E/M service is reported with an Injection code (96372-96379), will Oxford reimburse for both*

A: Yes, Oxford will reimburse for the Injection procedure and the Preventive Medicine E/M Code. When an evaluation and management (E/M) service and a procedure are submitted for the same member on the same date of service, there is a presumption that the E/M service is part of the procedure unless the physician identifies the E/M service as a separately identifiable service. Since the Injection procedure does not include the components of a Preventive Medicine E/M service, the Injection can be reported separately and the Preventive Medicine E/M code does not need a modifier to indicate it is distinct or separate from the Injection procedure

Deleted CPT code and new one 

The “Medicare Claims Processing Manual,” Chapter 4, Section 20.4, states: “The definition of service units… is the number of times the service or procedure being reported was performed.” In addition, Chapter 1, Section 80.3.2.2, of the manual states: “In order to be processed correctly and promptly, a bill must be completed accurately.” MLN Matters® Article MM3818 (Revised Coding Guidelines for Drug Administration Codes), states that the definition of the “initial code is amended to state that the initial code best describes the key or primary reason for the encounter and should always be reported irrespective of the order in which the infusions or injections occur." This is a clarification of the Transmittal 129 definition that the initial code is “the code that best describes the service the patient is receiving and the additional codes are secondary to the initial code.” If more than one initial service code is billed, the carrier will deny the second initial service code using remittance advice remark code of M86 to show that it is not payable unless the patient has to return for a separately identifiable service on the same day or has two IV lines per protocol. MLN Matters® Article MM6349 (Revised Coding Guidelines for Drug Administration Codes), provides renumbered CPT codes. Effective for CY 2009, the following CPT

codes have been renumbered:

Deleted CPT Code New CPT Code Short Descriptor
90760 96360 Hydration iv infusion, init
90761 96361 Hydrate iv infusion, add-on
90765 96365 There/proph/diag iv inf, init

The Recovery Auditor conducted an automated review of these codes in order to identify claims in which more than one (1) unit of service is reported and, as a result, over- reimbursed per CMS references are noted in the section below. Guidance to Provider to Avoid Coding Errors

–Ensure that you understand and comply with the Medicare policy for Codes for Chemotherapy Administration and Non-chemotherapy Injections and Infusion, which states that each of these codes is to be reported only once per day. The physician reports only one “initial” service code unless protocol requires that two separate IV sites must be used.

–If more than one “initial” service code is billed per day, the MAC shall deny the second initial service code, unless the patient has to come back for a separately identifiable service on the same day or has two IV lines per protocol. For these separately identifiable services, the physician reports with modifier 59. Each of these codes is to be reported only once per day.

–The definition of the “initial code” is the code that best describes the key or primary reason for the encounter and should always be reported irrespective of the order in which the infusions or injections occur.

ICD-10 Codes that Support Medical Necessity


ICD-10 CODE DESCRIPTION

E11.649 - E11.69 - Opens in a new window Type 2 diabetes mellitus with hypoglycemia without coma - Type 2 diabetes mellitus with other specified complication

E13.649 - E13.69 - Opens in a new window Other specified diabetes mellitus with hypoglycemia without coma - Other
specified diabetes mellitus with other specified complication

E83.52 Hypercalcemia

E86.0 - E87.0 - Opens in a new window Dehydration - Hyperosmolality and hypernatremia

I95.9 Hypotension, unspecified

K29.00 - K29.91 - Opens in a new window Acute gastritis without bleeding - Gastroduodenitis, unspecified, with bleeding

K52.89 - K52.9 - Opens in a new window Other specified noninfective gastroenteritis and colitis - Noninfective
gastroenteritis and colitis, unspecified

K92.0 Hematemesis

N18.3 Chronic kidney disease, stage 3 (moderate)

O21.1 - O21.8 - Opens in a new window Hyperemesis gravidarum with metabolic disturbance - Other vomiting complicating
pregnancy

R11.10 - R11.12 - Opens in a new window Vomiting, unspecified - Projectile vomiting

R11.2 Nausea with vomiting, unspecified

R19.7 Diarrhea, unspecified

R41.0 Disorientation, unspecified

R41.82 Altered mental status, unspecified

R42 Dizziness and giddiness

R55 Syncope and collapse

Z51.11 Encounter for antineoplastic chemotherapy

Z91.89 Other specified personal risk factors, not elsewhere classified

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