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