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Ask a Rev Cycle Expert: Infusion/Injections in Observation?


A patient was in observation for two days. If the patient is given hydration on Day 1 and an antibiotic infusion on Day 2, how should we report the CPT® codes by date of service?


From a Medicare perspective, the Centers for Medicare & Medicaid Services (CMS) states that only one initial drug administration service should be reported per encounter. Using the injection and infusion (I&I) hierarchy, Current Procedural Terminology (CPT®) code 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour would be reported as the initial service, using the date of service of the administration. Because hydration is lower in the I&I hierarchy than a regular infusion, the add-on code 96361 Intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure) with the date of administration as the date of service should also be included.

Disclaimer: This information was current at the time of its publishing and is designed to provide accurate information in regard to the subject matter covered. Vitalware does not accept any responsibility or liability with regard to any errors, omissions, misuses, or misinterpretation by the reader. It is not intended to take the place of either the written policies or regulations. We encourage you to review the specific regulations and other interpretive materials as necessary. All CPT® codes are trademarked by the American Medical Association (AMA) and all revenue codes are copyrighted by the American Hospital Association (AHA).