Volume 4, #2

July 2007

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Completely Document IV Infusion for Optimal Reimbursement

Candace Shaeffer, RN, MBA, RHIA
Chief Compliance Officer

The CPT rules for coding intravenous (IV) infusions require documentation of the infusion’s duration. For Medicare and other payers, hospitals are reimbursed for the first hour of the infusion and also for each subsequent hour. Often, nursing documentation is insufficient to determine the exact span of time that an IV infused; the start and stop clock times are required to determine the exact length of an infusion and frequently the infusion stop or discontinue time is left out of the nursing documentation. This leaves coders in a quandary.

The Centers for Medicare and Medicaid Services (CMS) requires that coding be based on documentation provided in the patient’s medical record. The Office of Inspector General (OIG) in their 2005 OIG Supplemental Compliance Program Guidelines for Hospitals stated that all documentation supporting claims for reimbursement from Federal health care programs must be complete and accurate and must reflect reasonable and necessary services ordered by a professionally licensed and participating medical professional. The OIG further cited insufficient documentation as one of the reasons for inaccurate or incorrect coding and upcoding: "Hospitals should also review their outpatient documentation practices to ensure that claims are based on complete medical records and that the medical record supports the levels of service claimed."

LYNX has provided the infusion documentation requirements and information to clients and, in addition, coders have provided feedback on individual encounters where documentation deficiencies were noted. While we were making efforts to assist nurses to improve documentation LYNX coders have used other clues in the record to determine the stop time of an IV infusion when it was not explicitly documented. Absent information otherwise, coders were allowed to count infusion time up until discharge from the ED or admission to the hospital since from a clinical process perspective this would be when the IV infusion would either be discontinued or no longer managed by the ED nurse.

Fortunately, as a result of these and the EDs own documentation, improvement efforts the infusion documentation has improved in most EDs. Given this improvement, LYNX will revise its coding policy for infusions and require coders to code them based on explicit documentation such as start and stop times or the noted time at which an infusion rate changed to a slower keep open rate. When a stop time or other monitoring information is not documented LYNX coders will default to coding only the minimum first hour of infusion.

CMS has not provided much direction to providers on this issue, but one CMS Fiscal Intermediary (FI), Wheatlands Administrative Services, for Kansas has posted an answer to this question on their Web site. When asked how to code a hydration infusion service when a stop time was not documented, the FI responded that if the record clearly indicated that IV fluids were initiated and infusing, the first hour of infusion could be charged and also that it would not be appropriate to bill for an injection service (defined as including infusion services lasting 15 minutes or less).

See FAQ #7 at: http://www.wheatlandsadmin.com/part_A/faqs/faq_ACT_022007.htm

The Medicare payment for IV infusions is $111.20 for the first hour and $24.25 for each additional hour (after a minimum 31 minutes of additional infusion time). Based on the volume of infusion services in a typical ED and the length of time they usually run, if infusions lack sufficient documentation to be coded for the full duration, hospital EDs will leave significant revenue on the table. In order to realize optimal reimbursement for services provided in an ED or other outpatient setting nurses must thoroughly and accurately document them. So what are the infusion data elements must be present in the medical record to ensure good clinical documentation and sufficient information for coding an IV infusion service?

• The location of the IV for each IV started, and the number of insertion attempts
• The catheter gauge, size and type
• The start and stop or discontinue (dc) times for an IV infusion or infusions
• The initial volume of fluid in the IV bag (eg. 50cc, 100 cc 1000cc)
• The rate of infusion, including if TKO/KVO and the times of any changes in infusion rate
• The type of fluid infused for each infusion ordered and any additives such as medications
• The type of infusion e.g. IVPB, IVP, IVSS, bolus, etc.
• Whether the infusion was placed on IV Pump
• Whether the IV catheter was placed to, or if an infusion was converted to, a saline lock
• If blood was drawn for labs with the initial IV start
• The amount of fluid remaining in the bag upon admission or transfer
• The nurse’s monitoring of IV infusions and whether the IV continued to infuse upon admission or transfer
• The d/c time of each IV catheter, and final assessment of the IV site
• The amount of fluid infused
• A physician’s order for each infusion.

LYNX coders will continue to work with ED nurses by providing information and feedback when their documentation is insufficient to support IV infusion coding. However, there are other ways in which LYNX can assist EDs to improve the documentation of IV infusions and monitor infusion charges:

• LYNX coding operations managers are avail- able to work with ED managers to revise clini- cal nursing documentation forms to include prompts for complete infusion documentation
• LYNX can provide a nursing documentation template which includes fields for each of the IV infusion data elements noted above—see Figure 1A (PDF) .
• On request, LYNX will provide additional infusion documentation information for nursing staff
• Monthly CPT utilization reports are available in LYNX software tools that will allow a manager to benchmark and track IV infusion and injec- tion frequencies and revenue.

The coding policy change for infusions will be effective for date of service August 1, 2007. For services occurring on or after that date, LYNX coders will look for specific documentation noting IV start and stop times as well as the number and timing of infusions. If a stop time is not present, only the first hour of infusion will be coded.

Should you have uestions, please contact your LYNX coding operations manager or account executive at 800.767.5969.