6 Reasons Why Infusion Coding is So Challenging

infusion coding challenges

Despite tens of thousands of individual codes that account for practically every procedure and activity in healthcare today, the coding process is still relatively straightforward. There’s a single code for a single procedure or activity. As long as the right code is applied, accurate billing and payment follow.

That’s not the case with infusion coding. Not only does it present a number of challenges on the front end because of its complexity, but those challenges create additional problems on the back end for coders and revenue cycle administrators.

Key Infusion Coding Challenges

Here are six challenges that make infusion coding so challenging for revenue cycle professionals.

  1. Nurses Shouldn’t Have to Code
  2. The Complexity of the Hierarchy of Infusion Codes
  3. Estimating or Missing Stop Times
  4. Lack of Infusion Coding Training
  5. Missing Hydration Charges
  6. EHRs Don’t Do Infusion

Nurses Shouldn’t Have to Code

While it may seem obvious that nurses should be concentrating solely on patient care, the reality is far different, especially when it comes to infusion events. Nurses administering drugs for infusions must not only have high emotional intelligence in caring for patients filled with fear and uncertainty, but they are also expected to enter the proper codes associated with infusions. That means not only do they have to stay up-to-date on the latest science associated with cancer care and other maladies, but they must also understand CPT codes well enough to be able to enter the proper data. It’s unfair. It’s as if they are expected to have two degrees – one for nursing and another for coding – and they are expected to be equally competent in both areas. The simple fact is, when it comes to infusions, nurses shouldn’t have to code.

Some organizations acknowledge this fact and, in fact, don’t allow their nurses to code. Instead, they bypass them and let qualified coders handle everything. While this relieves the nurses of the responsibility, it adds additional burdens to the coding team. Hospitals will often handle this challenge by adding more coders.

But adding more coders also means adding more costs. For example, if six coders are assigned to recording and reconciling infusion therapies and they are each paid approximately $60,000 a year, that’s an additional $360,000 a year in expenses dedicated to infusion coding. In an era of cost-cutting and belt tightening, that expense can seem like a lot of money being spent on solving one coding challenge.

The Complexity of the Hierarchy of Infusion Coding

One of the primary reasons nurses shouldn’t have to code revolves around a complex hierarchy of rules related to injections and infusions. For example, if a patient receives an infusion for a therapeutic drug and receives the same drug as a short “push” an hour later, the rules use one code for the first infusion and a second code for the shorter IV. Similarly, therapeutic infusions, which includes chemotherapy and non-therapy events) have their own set of rules. Separate codes exist for initial, sequential and concurrent infusions, and how long an infusion is administered determines which code is used.

The same is true for the order in which an infusion is administered. Chemotherapy infusions takes precedence over non-chemo infusion which takes precedence over hydration therapy. Even for coders, this complexity is daunting. For nurses, it’s an even greater challenge. Not only do they have to fully understand and apply this hierarchy, but they often have to do the math associated with the coding in their heads or on paper.

Estimating or Missing Stop Times

Another challenge associated with infusion coding is a nurse estimating or forgetting to put in a stop time for the infusion event. Why is this a challenge? There are several reasons. First, if hospitals charge and bill for infusion events based on the amount of time required to administer the drug, then it’s critical that the time be accurate. A nurse failing to enter a stop time means that person or a coder must backtrack and try to determine the proper timeframe for the infusion service in order to prepare a proper charge. That’s additional time spent away from other, more urgent needs, including patient care, and it means additional costs incurred.

Another reason missing a stop time creates a challenging environment is because of compliance. Auditors want to know that a hospital’s billing matches its documentation. If the documentation is inaccurate because it’s not clear when a drug during infusion was completed, then that environment creates a red flag for auditors and may result in a writeup or fine.

Estimating stop time creates its own set of challenges. In addition, the problems described in the previous paragraphs, infusion stop times that are estimated and not exactly recorded may result in a hospital not getting reimbursed for the amount it’s due.

Take an infusion that lasts 17 minutes and another one that lasts 14 minutes. If both are estimated or “rounded off” to 15 minutes, a hospital is missing out on being able to charge for a long infusion with the 17-minute therapy. Those additional charges can result in significant missed opportunities for additional revenue, especially if a hospital administers a high number of infusion events. For example, an organization with nearly 100,000 infusions could be failing to adequately charge for events that would have generated $3 million in additional revenue. This is money owed to the hospital, but not collected since the stop times were not accurate. That’s money being “left on the table.”

Lack of Infusion Coding Training

Another challenge associated with infusion coding is the lack of adequate infusion training for coders. Because of its complexity, infusion coding requires extensive training, whether it’s for nurses or professional coders. Unfortunately, many hospitals do not invest in that training. As a result, the coders or nurses are often left to learn the proper documentation on their own or through trial-and-error.

Missing Hydration Charges

Another area of concern related to infusion coding revolves around hydration therapy. It’s not unusual, for example, hydrations to not be recorded at all, thereby causing a hospital to once again miss an opportunity to charge and bill for payments owed to them. There can be several reasons for the omission. In an Emergency Department, for example, nurses simply may not have the time to record hydrations, especially in a busy environment with a high volume of patients. Second, because of the complexity associated with recording concurrent therapies, some organizations don’t even try to record and bill for hydrations. The irony is – hydrations make up a large percentage of all infusions. In fact, some experts believe they account for one-half of all infusion events. As a result, if an organization is not accurately billing for all hydrations it administers, then once again it is not getting paid for the services owed to them. That’s unreported or underreported income.

In addition, the same dilemma that occurs with chemotherapy infusions also occurs with hydrations in which inaccurate stop times result in the underreported charges and billing. Take a hydration that lasts  91 minutes. If the documentation records that hydration for only 90 minutes, the hospital is missing out on being able to charge for the correct number of units and bill accordingly. Again, that’s money “left on the table.”

EHRs Don’t Do Infusion

Finally, another challenge associated with infusion coding is that all of the current Electronic Health Records (EHR) systems don’t handle the complexity of infusion coding. While EHRs have transformed healthcare and have come a long way in the last 20 years in terms of documentation, they are not proficient at billing for infusion therapies. That goes back to the complexity of the infusion codes and its hierarchy. The dropdown menus of the major EHRs do not have the necessary calculations built into them to handle that complexity. As a result, nurses and coders must rely on their own expertise or calculations to adequately perform the function.

What are the Best Solutions to these Challenges?

Several solutions exist for hospitals if they are faced with challenges associated with infusion coding.

One solution, which is a common one, centers on simply adding more human resources. Whether they can afford to or not, some Revenue Cycle administers have re-directed coders from other areas to specifically tackle infusion coding issues and try to avoid bottlenecks and long lag times. In other instances, administrators have simply hired more people to attack the problem. Unfortunately, both solutions can be expensive. Obviously, adding more staff adds more costs. But similarly, re-directing staff also adds cost, since it means there are likely to be shortages or backlogs in other areas or departments. Fixing infusion issues with additional resources has proven to work, but it can also be expensive.

Another solution, albeit a reluctant one, might involve cutting back on infusion services or eliminating it completely. Rarely is this done, but it’s not out of the question if the hospital feels it can’t sustain and support the service, especially on thin margins. Another related option might be to outsource the infusion services to third-party to let them absorb the financial risks. For larger organizations with a high volume of infusions, neither of these alternatives is probably very attractive.

Perhaps the best solution to the challenges associated with the coding of infusion therapies is to turn to software and automation. MedAptus, for example, developed software, called CHARGE INFUSION, that benefits hospitals in several ways. First, it automatically calculates the hierarchy of codes associated with infusions. It runs thousands of rules and algorithms to each infusion event to correctly identify and then match the proper CPT code. In other words, it combines the hierarchy of codes (including the order of administration) with the drugs utilized and the start/stop times to create a 100% accurate code, which is then passed on to billing. And because the entire process is handled without human intervention (the nurse only needs to record the start and stop times and drugs utilized), no coders or nurses are needed to compute the right code.

There are several implications associated with the software. First, coders who were dedicated to infusion coding can now be re-directed to more urgent areas. For example, one cancer center was able to reduce the total number of coders it used for infusions from 6 to 2. Second, because the start and stop times can be accurately calculated, hospitals are now able to perfectly match their documentation with their billing. Not only does this typically mean more revenue generated, but it also ensures 100% compliance. Finally, because the software is fully compatible and compliant with all of the major EHRs (CHARGE INFUSION is currently available in the Epic App Orchard), the user is able to benefit from the software with minimal disruption.

The future holds additional promise as well. As smart pumps begin to become more ubiquitous in hospitals and automatically record start and stop times plus the drugs utilized, CHARGE INFUSION will continue to convert that data into accurate codes, making the entire process even more user-friendly and compliant.

Infusion coding doesn’t have to be a huge headache for revenue cycle departments. With some highly targeted assistance from sophisticated software, it can actually be a more efficient revenue producer instead of an ongoing cost center.

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Gary Bernklow is the Charge Product Director at MedAptus. He has 30 years experience in hospital revenue cycle management, including coding, billing, and compliance.  He also has 11 years experience with outpatient hospital infusion coding and billing. Prior to his current role, he worked as the Lead Cycle Manager at Massachusetts General Hospital’s Medicine Department.