Rev Integrity Injections Infusions Icon
Revenue Integrity: Injections and Infusions

Reducing touches/rework  //  Difficulty: Moderately Simple  //  Revenue Cycle Operations

Why run this play?

Consider this scenario, which happens frequently: A physician orders three hours of hydration, as well as a one-hour therapeutic antibiotic infusion for a patient. A nurse documents the hydration start time as 10 a.m. and the antibiotic start time as 11 a.m., but doesn’t document a stop time. Without stop times, coders struggle to be fully compliant, resulting in compliance risk and lost revenue. This play details simple steps that let providers code and bill the correct amount for service.

Background

The American Medical Association (AMA) created different codes for “initial” and “subsequent” administrations including coding guidelines that state there should be only one initial code per encounter, unless two separate access sites are required. Hospitals and providers must ensure that units of drugs or biologicals administered to patients are accurately reported in terms of the dosage/units specified in the complete HCPCS code descriptor. CPT guidelines include a hierarchy for coding injections and infusions. If information gaps exist and/or coders aren’t familiar with this hierarchy or don’t follow it, overcoding and undercoding can occur.

Take Action

  1. Create fatal edits to hold claims in the DNFB where the patient service location is IV Therapy and where the stop time is not populated. 
  2. Segment IV and Infusion Therapy cases in the DNFB, prioritizing payers where missing charges may impact reimbursement. 
  3. To get a sense of your biggest issues, create a series of reports that track denials related to revenue integrity injections and infusions. Identify root causes (by area, facility etc.) and update processes to reduce denials.
  4. Create reports on your active A/R to show all accounts that don’t meet the correct criteria (missing start times, missing initial injection code etc.).
  5. Create look-back analysis where injection and infusion topics resulted in the over-contractualization of a denial.
  6. If any account triggers your variance reports, immediately address the situation before billing.
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How to Calculate This Play's Value

  1. Measure DNFB Beyond Suspense by Disposition. Monitor and trend holds for missing stop time. If there is no reimbursement tied to fixing the problem, the value is in improved revenue Integrity and recognition given to the originating revenue center, along with reduced rework on downstream revenue cycle functions. Where this reimbursement is associated with ‘the fix’, the value of this play is measured by the reduction in contractuals and the incremental increase in net revenue.
  2. Measure the denial trend related to Infusion and Injectables to see if the denial rate is going down. 

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