03/06/2018

"Ask MSHO"

March 2018, Frequently Asked Questions

Question: 

In the CPT book it states, Hydration is described as an IV infusion to consist of a pre-packaged fluid and electrolytes (eg, normal saline, D5-1/2 normal saline+30mEq KCI/liter….)

We purchase normal saline bags and add potassium.  It is cost effective for our practice.  Is this still considered pre-packaged fluids?  Should we switch to billing therapeutic infusion codes since it was not shipped to our practice in the pre-packaged situation?  Also, what if we add magnesium?  Would that be hydration or therapeutic?  Does it depend on the amount?

Answer: 

If you were treating your patient for dehydration and using pre-packaged fluid or the equivalent of pre-packaged fluid, you would bill hydration (as long as it is not concurrent with other medications and longer than 30 minutes). 

If you are treating the patient for a condition or to prevent a condition such as nephrotoxicity, and you are administering 1 gram of potassium or magnesium for example, then this would be billed as a therapeutic infusion during the time it runs alone.  This higher dose of electrolytes cannot be purchased as pre-packaged fluid.

Question: 

Drug: Ativan J2060 - IV infusion over 16 minutes, but it is given over 15 minutes and it is billed as 96367.  The time tells me it is not an IV infusion, it is a IV push.  But I don’t have an order noting that it must be given IV push.  The order says IV Infusion.  Technically, should it be billed as an IV push?  Please advise.

Answer: 

The nurse must follow the physician order.  If the order says to administer over 15 minutes IV - and the nurse gave it over 15 minutes IV, you will bill for a 15 minute IV infusion.  The extra minute the nurse documented would not be “medically necessary” if the physician order stated to give over 15 minutes.  With that said, in order to BILL a 15 minute IV infusion - YOU, the biller, must use the push code on your claim per the AMA CPT requirements.  Technically you are still billing an IV infusion.

Question: 

If we come across an order that is not signed in the EMR can we sign the order when found?  If not is there any way to correct this after the fact?

Answer: 

Essentially, if the nurse administers a drug without having a signed order, they are in violation of the state law and therefore, adding a late signature will not correct the situation.  Medicare policy states; “If the signature is missing from an order, ACs, MACs, PSCs, ZPICs, and CERT will disregard the order during the review of the claim.    If the signature is missing from any other documentation, ACs, MACs, PSCs, ZPICs, and CERT will accept a signature attestation from the author of the medical record entry.”  The only variable I can think of is the situation where the order was documented as a verbal order- a late signature in that situation may be acceptable as long as the signature is dated and “authenticates” the verbal order.

Question: 

With verbal orders is there a time limit for those to be signed off by the physician?

Answer: 

I have not seen requirements within the CMS online manual related to the time frame of the signature specific to verbal orders.  In fact, in 2011, CMS attempted to pass policy that required verbal order signatures within 48 hours.  That rule was rescinded on July 16, 2012; it was stated in the Federal Register, “Verbal Orders:  We have eliminated the requirement for authentication of verbal orders within 48 hours and have deferred to applicable State law to establish authentication time frames.”

However, WPS Medicare has documentation requirements within their website that states:

"Physician offices should have a protocol in place to have physicians sign their records within a reasonable time, generally 48 to 72 hours after the encounter, but certainly prior to submitting the claim to Medicare."

Another Medicare MAC, Novitas states on their website: “If the order is verbal, follow it within 14 days by a signature to be timely.”

Question: 

Would you mind clarifying the proper use of 96368 for billing in chemotherapy.  So many of our payers are not paying for this code and some denials are for “incidental to” denials.  Can we bill for the 96368 if they are a therapeutic drug and a chemotherapy drug going to the same access site?  Can we only bill the 96368 when they are concurrent and going to different access sites?  I have gotten so many different answers and feel that you could answer this question once and for all.

Answer: 

I used to call it "Concurrent Confusion" because it is challenging to understand.  If you have a therapeutic agent, in a SEPARATE BAG, hanging at the same time as another - (concurrently) - then you can use the code.  Some payers look for a 59 modifier on the 96368. 

The AMA defines a concurrent infusion as one in which two drugs are simultaneously infused or multiple infusions are provided through the same intravenous line. Note: Multiple substances mixed in one bag are considered to be one infusion, not a concurrent infusion.

There is no concurrent code for hydration.  The concurrent CPT/Charge is limited to unit of one regardless of the duration of the concurrent infusion.