Injection and Infusion Coding 101

Coding and Billing of Injections and Infusions hasn’t changed much under CPT, yet hospitals and practitioners continue to face problems with correct coding. Any number of issues arise, from correctly coding hydration and therapeutic infusions to reporting multiple services rendered during the same visit. It may not seem that way but injection and infusion coding is a labyrinth. Never fear! This post will help clarify some of the basics of injection and infusion coding.

Definitions of Important Terminology

Under Current Procedural Terminology (CPT), the definitions of injections and infusions are as follows:

An ‘Injection’ delivers dosage in a single shot rather than over a period of time. It can be administered from various routes such as subcutaneous, intramuscular, intraarterial and intravenous. An injection is usually used when Medication needs to immediately affect the patient. IM (Intramuscular) and SQ (Subcutaneous) injections should be documented separately. An IV (Intravascular) injection is directly injected into a vein, or the port of an IV infusion or hep/saline lock or an infusion (including IVPB (piggy back), IV bolus or infusion through a large volume syringe).

An ‘Infusion’, on the other hand, is the administration of intravenous fluids and/or drugs over a longer period of time. Infusions are provided through saline or other solutions over a period of time.

Infusion definitions consist of the following:

• Hydration- an IV infusion consisting of prepackaged fluid and electrolytes.
• Therapeutic infusion- the parenteral administration of substances/ drugs for therapeutic, prophylactic or diagnostic purposes.
• Subsequent infusion- a therapeutic infusion following another.
• Concurrent infusion- multiple therapeutic infusions provided simultaneously through the same intravenous line.

Documentation Requirements

For Injections- The name, strength and dose of the drug administered need to be reported, along with the method of administration, i.e. IM, SQ, or IVP (push). Mention the specific site of the injection i.e. the body part and time of start or completion.

Tip: Always use IVP not IV in documentation as IV is a vague term which does not specify whether the method was an injection or infusion.

Always document the specific substance administered, since subsequent injection codes are based on whether the administered drug is the same or different.

For Infusions- The name, strength, and dose of the drug should be mentioned, as well as method of administration (IVPB). Mention the site of administration, rate of infusion, total volume infused and total time/duration of infusion.

Multiple infusions of different drugs or substances can be reported separately. Services included but not reported separately under coding guidelines are the use of local anesthesia, intravenous (IV) start, access to indwelling IV, subcutaneous catheter or port, flush at end of infusion and standard tubing, syringes and supplies.

Procedure for correct coding

Determine the patient’s purpose in visiting the healthcare provider as well as the type of treatment as a starting point. Then check the treatments the patient actually received, for example, chemotherapy, non-chemotherapy, injection etc. The hierarchy of coding is essential here for determining which procedure should be coded as the initial treatment. Define the specific method of administration, i.e. IV infusion, IV injection, SQ, IM or combination. Next, mention the duration of the process, i.e. less than 15 minutes, 15+ minutes, first hour etc.

Hopefully this blog has cleared some aspects of coding and billing for injections and infusions. To get a detailed account of the correct coding guidelines including the CPT coding hierarchy, and insight into reporting multiple services rendered during the same visit, and other related topics, check out these expert-led webinars on Hospital coding.