Infusion coding continues to be a “hot spot” for CMS and private payor audits.  The evolution of these codes has created several vulnerabilities.   First, within a 5 year time frame, infusion CPT codes have been revised, transitioned into Level II HCPCS codes and then re-categorized within the 90,000 series of CPT services.  Beyond this, the rules have continued to change with respect to bundling edits, supervision and general use of the codes depending on the site of service.

No surprise, most of the RAC’s have issued audits focusing on infusion services and specifically hydration.  Although the RAC has defined the audit as a review of “units” per patient per date of service, clinics and facilities should realize that other types of audits may look deeper into other issues surrounding infusion/hydration billing.  Likewise, some of the other RAC issues may incidentally create opportunities to find overpayments.  One example is blood transfusions.  Although both hydration and blood transfusion are defined as “automated audits”, it may create a complex review opportunity if both services were billed and paid at the same visit.  Coding rules dictate that although these services may be performed together, hydration services are bundled as part of the overall transfusion service and therefore should not be paid separately.

Most recently, the OIG issued a report dated July 28, 2010 on payments received by Princeton Community Hospital from its Medicare contractor for outpatient infusion therapy services. The OAS (office of Audit Services) found that Princeton Community Hospital billed for infusion services during surgical services and received payment over and above the global package. The report stated that “Payments received by the hospital from its Medicare contractor for 762 claims were not appropriate because they were for outpatient infusion therapy services provided as part of a surgical procedure and therefore were not separately payable by Medicare.”

A few suggestions on conducting internal reviews to detect potential problems

• Cross check physician/nursing time against unit value time on claims. As per CPT, time under 31 minutes may not be billed as a separate service.
• Cross check multiple infusion services for facilities as CPT has specific hierarchies based upon structural algorithms.
• Cross check surgical services and items billed “over and beyond” on the same date of service.  Multiple procedures should have modifier -51 appended (unless exempt).  Review modifier -59 criteria and non-surgical services billed and paid on the same date as a surgical service.
• Review infusion services performed “concurrently” as services such as hydration are bundled into other infusion services.
• Review “start” and “stop” times of infusion as time is only calculated when medication/hydration is going into the patient.  Prep and observation time are NOT a part of infusion time.
• Review billed equipment and supplies associated with infusions.  Items such as local anesthesia, IV access, flushes and standard tubing, syringes and supplies are bundled into the infusion service.

Jana Gill is a Certified Professional Coder and MedMan’s Coding and Compliance Director.   Jana offers audit, coding, training webinars, and other services for MedMan clients. For more information, contact us at 208-333-0000.