Vol. 18 • Issue 26
• Page 8
Diagnosis: Crohn's disease.
Order Information: Remicade 5 mg/kg = Total dose 300 mg in 250 ml 0.9% NaCl; and Benadryl 50 mg p.o.
ICD-9-CM DIAGNOSIS CODE
555.9 Regional enteritis, unspecified site
ICD-9-CM PROCEDURE CODE
99.29 Injection or infusion of other therapeutic or prophylactic substance
CPT PROCEDURE CODES
96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial up to one hour
96366 each additional hour (List separately in addition to code for primary procedure)
In the above documentation, you will see the nursing department utilizes a grid for the documentation of nursing interventions. Although there is a location of time for the start time, there is no area to document the stop time. The nurse must be diligent and document the time in the narrative, as has been done in this case.
Look at the start time for Remicade, which is 12:10, and then a note that at 14:10 Remicade infusion was complete. This is a total of 2 hours of infusion time.
Look up the term Infusion in the index where you will find several choices. The appropriate choice is Intravenous Infusion under which you will see the indented term Therapeutic . 96365-96368, 96379. A review of these codes in the main body of the CPT manual shows the correct code choice to be 96365 and 96366.
Peggy Hapner is manager of the HIM consulting division at Medical Learning Inc. (MedLearn), St. Paul, MN.