Sophie Posted Wed 06th of August, 2014 16:17:53 PM
If pt was seen in office for abd pain, diarrhea, nausea and vomiting. The physician decides pt needs fluids and Zofran how do I bill for that?
The infusion note reads:
#22G LAC STARTED W/ONDANSETRON 4 MG IV GIVEN AT 1040. PT ALLERGIES VERIFIED PRIOR TO GIVING.
1140 - BP 110/80, HR 70, RR 16. NAUSEA IMPROVED - CONT TO HAVE ABD CRAMPING. - DW1150 - INFUSION COMPLETE - AJD AWARE. IV D/C SITE CLEAR -DRSG APPLIED W/HEMOSTASIS ACHIEVED. D/C FROM CLINIC - TO GO HOME
Would I bill the above like I've listed below??
1) 96374 w/ dx 787.02
2) J2405 x4 units, w/ dx 787.02
3) 96360 x1 unit, w/ dx 276.51
4) J7120 x2 units, w/ dx 276.51
SuperCoder Answered Wed 06th of August, 2014 22:05:31 PM
You have coded this correctly. 96374; Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug. CPT 96374 describes the administration of substance or drug into the body for therapeutic, prophylactic, or diagnostic purpose involving single or initial substance/drug.
The Zofran is coded with J2405; Injection, ondansetron hydrochloride, per 1 mg. You would code this per mg just as you have done.
96360; Intravenous infusion, hydration; initial, 31 minutes to 1 hour would be billed with the J7120 for the lactated bag; Ringers lactate infusion, up to 1,000 cc. You may see it documented as lactated Ringers, lactated Ringers, or even LR or RL. The solution includes sodium chloride, sodium lactate, potassium chloride, calcium chloride, and sometimes dextrose. The doctor may use it to replace fluid or electrolytes.