Top 5 Best Practices For Complete Documentation Of Injections And Infusions

Administering injections and infusions entails numerous complexities owing to the extensive CPT instructional notes, hierarchical regulations, and varying payer directives. Leveraging outsourced medical billing can mitigate the challenges surrounding the reporting of drug administration services. Here, we've enlisted the best practices to reduce the confusion with coding injections and infusions.

Understand the Terms "Injections" and "Infusions"

Many of you might wonder about the difference between injection and infusion. Current Procedural Terminology (CPT) has defined the terms in the following ways:

• Injection- An injection administers medication via needle and syringe, such as a flu shot or vaccine. Types include intramuscular, subcutaneous, and intradermal injections, targeting muscle, fatty tissue, or skin layers.
• Infusion-  An infusion delivers fluids, medication, or blood via a catheter into a vein. A medical professional inserts the catheter using a needle, which is then removed, leaving only the plastic catheter. Specialty Infusion Centers solely administer fluids and medications mixed in fluids.

Tips For Reducing Confusion with Coding Injections and Infusions

A common area of noncompliance is the documentation and coding of injections and infusions, which also leads to high denial rates. This also tends to create confusion with coding infusions and injections. It's paramount to reduce the confusion and ensure an understanding of accurate documentation and reimbursement processes.

The Department of Health and Human Services (DHHS) and the Centers for Medicare & Medicaid Services (CMS) outline crucial elements for physician orders concerning drug and biological administration. These include the patient's name, age, weight, date and time of the order, drug name, dose, frequency, route, strength or concentration, quantity or duration, specific usage instructions, and prescriber's name.

For documenting infusion services, minimum requirements entail noting the substance (drug name), dose (volume and rate), route and site of administration, start and stop times for each substance infused, and identification of the administering clinician. Additional documentation on the Medication Administration Record (MAR) should cover patient vitals, tolerance, adverse outcomes if applicable, and drug wastage.

It's crucial to record infusion time accurately, distinguishing between IV Push and other infusion types based on duration. Follow hierarchy levels for reporting injections and infusions, prioritizing chemotherapy services first, followed by non-chemotherapy therapeutic, prophylactic, or diagnostic services, and finally, hydration infusions. The persistence of these guidelines ensures comprehensive and accurate documentation of drug administration procedures.

Tip 1: Be Informed and Updated With the Regulatory Changes

Given the dynamic nature of medical coding, it's crucial to stay abreast of the latest updates in CPT instructional notes, hierarchy rules, and payer guidelines. These guidelines evolve over time, reflecting changes in medical practices, technology, and reimbursement policies. Regularly reviewing these updates helps ensure compliance with current coding standards and minimizes the risk of coding errors that could lead to claim denials or audits.

Tip 2: Comprehensive Documentation Process

It is the cornerstone of accurate medical coding. Healthcare providers must document the details of each injection or infusion procedure, including the type of medication administered, the route of administration (e.g., intramuscular, subcutaneous, intradermal), and any complications encountered during the process. Thorough documentation not only supports appropriate code selection but also reduces the confusion with coding injections and infusions. It provides a clear record of the patient's treatment course, which is essential for continuity of care and clinical decision-making.

Tip 3: Be Clear About Start and Stop Time

When distinguishing between IV, push, or injection, ensuring documentation includes start and stop times is crucial. Without a stop time, an IV infusion can't be reported accurately, as it must last at least 16 minutes. IV pushes, however, can be coded for 15 minutes or less. Oncologists often face queries to clarify administration methods, and incomplete documentation risks revenue loss due to downloading. Proper documentation ensures accurate reimbursement, with IV infusions reimbursed higher than pushes.

Tip 4: Educate and Train Staff Members

Healthcare professionals, including physicians, nurses, coders, and billers, usually tripped up because of improper knowledge and skills for accurate coding of injections and infusions. Hence, it's crucial to educate and train healthcare staff members regarding the latest updates and changes in coding. Training programs should cover coding procedures, guidelines, and documentation requirements specific to drug administration services. With this, healthcare organizations can reduce coding errors, enhance revenue integrity, and promote compliance with regulatory requirements.

Tip 5: Expert Guidance and Help

In cases where coding injections and infusions prove particularly challenging or time-consuming, healthcare organizations may consider outsourcing medical billing to specialized professionals with expertise in coding drug administration services. Outsourcing medical billing can alleviate the administrative burden associated with coding and billing, allowing healthcare providers to focus on delivering high-quality patient care while ensuring accurate and timely reimbursement for services rendered.

Navigating the complexities and confusion with coding injections and infusions requires diligence, attention to detail, and ongoing education. By following these aforementioned tips, healthcare organizations can reduce confusion, improve coding accuracy, and optimize the revenue cycle performance of medical coding and billing.