Outpatient infusion coding can be confusing to even the most seasoned coding professional. With its hierarchy of appropriate codes, its counterintuitive guidelines for multiple sessions in outpatient areas, the time-based billable unit volumes, outpatient infusion can be one of the most complex coding and billing environments in healthcare today.  

To deal with these complexities, these challenges might sound a little familiar:  

  • You use paper-based billing and coding systems which can get lost or be inaccurate  
  • Clinical nursing staff have to decipher their own charges at the same time as they are documenting their services in the patient’s EHR 
  • You rely on a number of coding staff to review every infusion service performed  

Each solution carries its own advantages and disadvantages:  

  • Paper gets lost, and still requires resources to input data
  • Clinical staff do not have the coding expertise to assure accuracy, nor do they want to perform a function outside of their training.
  • Coders can be very costly.

But there is another option for creating complete and compliant infusion charges: Automation.  

The challenges of outpatient infusion coding

Everything required to produce complete and compliant infusion charge codes is available and documented in the patient’s record. While the coding is complex and confusing, clinical staff are typically trained to include start and stop times, drugs infused, the route of administration, and the site of administration in all their documentation. Infusion coding rules, while complex, are also absolute.  

Codes as created according to a specific hierarchy—chemo drugs before therapeutic drugs before hydration drugs—and the number of units of each is directly determined by the duration of the infusion itself. Unlike most medical procedures and services, infusion coding is actually more like a mathematical equation, one that lends itself directly to being automated. 

There are several software options to help automate infusion coding. Nearly all of them rely on a user to enter basic information directly into the software like drug codes and start and stop times. The software then uses that information to calculate the correct billing codes and will either send that charge information to your billing system or produce a spreadsheet whose data needs to be transferred by another resource into the billing system. While useful and typically more accurate than relying on coder knowledge alone to create billable codes, the process is nonetheless duplicative. That same information has already been documented once in the patient’s EHR record and then must be entered again to create billing codes. This double effort dramatically reduces efficiency. 

Fully automated infusion coding, on the other hand, pulls that same information out of the EHR, sends the data through the infusion “calculator,”, and produces billable codes without any need to manually input data. The information has already been recorded once, so use it. 

Let’s explore the top five benefits of fully automated infusion coding: 

  1. No more inaccurate codes: With a fully automated application, the resulting billing codes will match the documentation on the service 100% of the time. It has to because they are the result of an automated calculation. The codes would not have been created without that documentation. The coding is always accurate and compliant. Due to the complexities of the coding, hospital outpatient infusion services are a favorite target for RAC auditors, and fully automating your infusion coding can be a tremendous tool to help your organization eliminate vulnerabilities.
  2. Reduce the need for coder-created charges and allow them to focus on charge “exceptions” instead: Coders do not have to review every clinical document for every patient receiving an infusion, then generate the codes based solely on their own expertise. Instead, they can focus on those charges that have some kind of problem. For instance, medaptus Automated Infusion software can warn customers whenever there is an infusion service that is missing a stop time. Those services are allowed to be charged as a “push” with current billing regulations, but pushes are paid at a lower rate than a longer infusion (one at least 16 minutes long, for instance). Was the service actually a push or was the stop time simply left out of the documentation? If the latter, the charge can be placed on hold and then investigated by the coding staff. If the documentation needs to be corrected with a correct stop time, the new data can be retrieved from the EHR, and the new billable charge is calculated by the software. The result might be an additional payment for the actual services performed rather than settling for a lower reimbursement due to missing documentation. Focusing on charge “exceptions” can therefore lead to better documentation through direct feedback to the clinical staff. 
  3. Reduce inefficiencies and the number of resources required to produce compliant codes. This makes the revenue cycle process much more efficient. The number of coding staff required to process infusions correctly can be reduced by up to 80%. Given the scarcity of coders available, those resources can then be directed elsewhere to other potentially problematic areas of the organization. Coders usually appreciate working on different and diverse issues, but often good infusion coders are tied to that specialty due to their success.  
  4. Remove the burden of coding from your nurses. Do not underestimate the positive impact on your clinical staff either. If you are requiring your infusion nurses to both document the services they provide and then attempt to code for those services as well, that is likely to be a dissatisfier for them. Most nurses do not want to be coders too. Most will be delighted to remove that responsibility to be able to better focus on the needs of their patients. 
  5. Efficiencies and correct coding equals impressive financial returns. One of the most important results of automating your infusion coding is the potential for impressive financial impact. Administrative efficiencies gained can be as high as 80% overall. Keep in mind that automation can be implemented anywhere that infusions are delivered in any outpatient clinic. That includes observation care units and emergency departments, both of which are considered outpatient departments by CMS. Data has shown that up to 1/3rd of all ED patients receive some kind of infusion, typically for hydration. With the bustle of a busy emergency clinic, staff can easily forget to properly document infusion stop times or forget to document a key piece of clinical information. Services with missing information can be flagged and held for review within the software for follow-up, and the organization can be reimbursed fully for the services provided.  

Additional positive financial impact can be gained by simply having more accurate coding based on exact infusion duration. The difference of even 1 minute in calculating infusion codes can mean a difference in reimbursement of up to $60. So, if your coders are calculating those durations in their heads and they make a math mistake, your organization is not getting paid appropriately. One large infusion provider had trained their coders to always round the infusion minutes down to the nearest 15-minute slice of time. That resulted in nearly $4 million in undercharged coding, fees they were due but did not bother to charge. Minutes make a difference and automating their calculation is a much more accurate method, better than even the most experienced coder.  

If you’re struggling with infusion coding and want to reduce the challenges involved, fully automated infusion billing can help. Our Infusion Charge application can use your already-documented infusion information and create compliant billing codes directly from that data. It is not computer-assisted coding, it is documentation-driven coding that will make your organization more efficient, your employees more satisfied, and your coding more accurate, ultimately ensuring you’re getting paid for every infusion you deliver.


About the Author

Gary Bernklow

Senior Product Director

Get the latest updates and news delivered to your inbox.

Subscribe to our newsletter today.