IV Coding Scenario #1
A 25-year-old male falls from a pickup truck bed. Ambulance arrives at 15:56 with an IV running. He complains of knee pain, a headache and shoulder pain. Bystanders thought he had a seizure that lasted only 1 or 2 minutes. He cannot bear weight on the injured knee and has limited mobility of the injured shoulder. He also has multiple abrasions on his anterior scalp, knee and both hands. He is brought back to the treatment area immediately on arrival. 30 minutes after arrival he experienced a witnessed grand mal seizure lasting about 3 minutes. He has been given Valium 4mg IV push to treat his seizure. After being stabilized, he was sent to MRI for a head scan.
A large bore IV line has been started by the paramedic while initial field evaluation was being performed. The ambulance arrived at 15:56. The IV is running at a rate of 500 cc per hour and there is approximately 600 cc remaining in the bag.
The physician orders the IV to be continued at 250cc while continuing to evaluate the patient’s injuries. The IV is stopped at 18:22.
A second bag of Normal Saline is hung at the same rate of 250cc per hour at 18:34 and continued until the patient is admitted at 22:01.
Dilaudid, 4mg, (Pain medication) is administered via IV push 10 minutes after arrival.
Valium 4mg was administered by IV push at 16:34.
The Dilaudid is repeated at 16:40.
The patient is given a Dilantin loading by IV infusion. It is started at 17:03 and stopped at 19:48 (what is the duration in minutes?)
The Primary Service Code is 96365, with two additional codes 96366, two push codes of 96375, a repeat code 96376, and one add-on hydration code 96361.
Key Learning Points:
- IV solutions containing Potassium additives are considered infusions and not hydration
- IV services are reported on a per “bag” basis. Each bag has a separate start and stop time and the gap in time between the end of one bag and the start of the next bag is not reported.
- Repeat of the same medication is not reported, unless the medication is administered more than 30 minutes later than the previously reported service
What is the “initial service”?
- In this case it is the infusion of Saline with Potassium added. The addition of the Potassium converts the hydration to an infusion for coding purposes.
- Even though the Dilaudid was given earlier in the treatment process, an infusion is always primary to an IV push.
IV Coding Scenario #2
A 42-year-old male comes complaining of severe flank pain. He has no history of recent trauma but has passed kidney stones in the past. An IV line is placed at KVO at 10:21 by the admitting nurse. Treatment course is outlined below.
Pain medication, Dilaudid 2 mg, administered via IV push 20 at 10:24.
Dilaudid 2 mg is repeated at 10:30.
IV hydration is ordered at 10:30 with Normal Saline at 500 cc hour. It is started at 10:42 by the staff nurse and is completed at 11:45.
Dilaudid 2 mg is ordered again at 11:50.
IV hydration is ordered to be continued for another liter of Normal Saline with 40MEQ of Potassium at a rate of 250 cc per hour.. The IV fluid is started at 11:55 and continued until 15:22.
Key learning points:
- When infusions and hydration services overlap, the duration of the hydration must be adjusted to prevent billing for two or more overlapping IV services at the same. This CPT coding rule applies to overlapping infusions and hydration services.
- IV push and IV hydration services can be either primary services or subsequent services. CPT designates the following sequence: IV infusion is primary to any IV push or hydration and if an infusion is not provided then IV push is primary to hydration services.
- If hydration services are provided when an IV infusion or IV push are also provided, the entire duration of the IV hydration service is reported using the sequential hour code, 96361.
What is the primary service?
The infusion of Dilantin is the primary service. It is reported as 96365, one unit. The duration of the infusion is 165 minutes so it exceeds the duration of the 90 minutes associated with 96365. To account for the entire duration of 165 minutes (2 hours, 45 minutes), two additional hours are reported as 96366. Note: 45 minutes is more than 30 minutes into the third hour so it is billed as a full additional hour.