Insurance will not pay for IV push if billed same day as an E&M

One of our primary Insurance companies refuses to pay for an IV pushes (cpt's 96374 & 96375)when an E&M service is billed same day. They feel the IV push is included in that office call ( like 96372 would be). When looking at CPT® guidelines it clearly shows that in a clinic setting IV therapy pushes,hydrations,etc... (only referring to Non-Chemotherapy) are a separate billable service with RVU's. Also the primary code would include the administration of fluid and or drugs,the constant presence of a trained healthcare professional, direct supervision,patient assessment,safety oversight,start of IV,supplies,flush at the end of infusion, etc..We follow the coding hierarchy rules which put the IV push primary to hydration. They will pay on the cpt96361 when IV hydration is billed sequentialy to initial infusion (IV push) but not for the that initial infusion when its a IV push. I have sent them information on supporting our claims and they just will not budge on this. At this point would it be appropriate to bill additional CPT® codes to cover the services that are normally part of that initial service. Such as starting IV CPT® 36600-36660, the intial hydration code 96360,rethinking the level of service billed to include the providers oversight, etc.. I feel if they are not paying according to the hierarchy that is in place for this it would then allow for us to bill accordingly. Was wondering if anyone had thoughts on this ?

re: Insurance will not pay for IV push if billed same day as an E&M

Is the E/M service for a significant, separately identifiable reason? I guess that is how I'd look at it. What is supporting the E/M and what is supporting the push. Medicare has edits on that for that reason, though they'll pay both services when it's separately identifiable.

re: Insurance will not pay for IV push if billed same day as an E&M

Is seems like you have a couple of different coding scenarios going on here and I will try to break them down one at a time;

First lets address the E&M services along with the IV pushes, if the patient is being seen and the appointment was booked just for the pushes, the only thing you should be billing is for just the pushes. To code for an E&M service you would have to use the modifier 25 which indicates that on the same day procedure or service identified by a CPT® code is performed, the patient's condition required a significant, seperately identifiable E&M code beyond the usual level of service required for the procedure. In addition , the modifier denotes the patient's condition required services that were above and beyond the ususal preoperative and postoperative care associated with the acutal procedure performed. So unless you did something outside of the original procedure, why are you billing for an E&M??

Seconandly I'm not sure what you are saying about the hydration codes, but CPT® does state that the hydration codes 96360 and 96361 are not to be used when the purpose of intravenous fluid is to "keep open" an IV line prior or subsequent to therapuetic infusion ar as a free flowing IV during chemotherapy or other therapeutic infusion. CPT® also states in small print to report 96361 to identify hydration if provided as "Secondary" or subsequent service after a different INITIAL service {96360 96365 96374 96409 96413 } is administered through the same IV access. So if you are billing 96360,96361, 96374 & 96375 they are not going to pay the initail hydration code 96360. CPT® states do not report 96360 if performed as a concurrent infusion service and since the administration of the fluid is conidered incidental, hydration and is not seperately reportable.

As for billing for the starting of the IV's with codes 36600-36660, these codes are for arterial puncture, catheterization or caulation , cutdown and the catheterization for a umbilical artery of a newborn. please read your codes carefully in the CPT® book and the start of an IV is part of the infusion, if you read the guidelines under the heading in your CPT® book stating "HYDRATION, THERAPEUTIC, PROPHYLACTIC, DIAGNOSTIC INJECTIONS AND INFUSION, ETC......it tells you the what the following services are included and are not reported separately.

If i have read any part of your email incorrctly please let me know, as I hope i have not misinterpetted and of the infusions codes wrong that you were referring to.
Respectfully,
L. Willilams, CPC

re: Insurance will not pay for IV push if billed same day as an E&M

I need to clarify. Here is the scenerio. Patient comes to clinic with nausea and vomiting as well as being dehydrated. Physician provides an E&M. They order an IV for hydration. During this patient is given an antiemetic for nausea via IV push. Same line. Hydration continues for an additional 1 hour plus. We would bill the E&M level with a modifier 25, the IV push would be considered the initial service so we would bill 96734 and because hydration lasted over an hour we would bill for the sequential hydration 96361. CPT® says a different diagnsis is not needed. The E&M service is supported because patient required a separate identifiable evaluation to determine course of treatment (thus , the mod 25 being appended). Insurance denies the 96374 because we billed an E&M. My thought is that the intial infusion code supports the IV start including access, supplies,the flush at the conclusion of infusion, the ongoing assessessment by nursing staff, as well as physician oversight. Using the IV push as the intial service would be following the hierarchy for billing infusions. Any thoughts on this? Thanks for any feedback