Q&A: Hitting MUEs for injections and infusions

Q: We have trouble billing multiple units of injections and infusions – mostly CPT add-on codes 96375 (injection, each additional sequential intravenous push of a new substance/drug) and 96376 (injection, each additional sequential intravenous push of the same substance/drug provided in a facility) – that are done during observation stays and exceed the medically unlikely edits (MUE) number. What is the correct way to bill these and get paid?

A: The current MUE for code 96375 is 6 and for code 96376 is 10. Some things to consider are: are the services being reported on the date of service on which they’re documented? For observation claims, the total number of observations hours must be reported on one line item on the first date of service, but that’s only applicable for the observation hours. Drug administration services should be reported based on the actual date they were provided. So for an overnight stay, you could have 96375 or 96376 reported on two dates of service (both before and after midnight).

Also, are you in the practice of defaulting to an IV push if you don’t have a stop time for an infusion? If you are, that will potentially run your units on your IV pushes up quite high.

Do you have a lot of infusions that are running in fewer than 16 minutes? You have to look at what’s causing the claim to hit the MUE. Usually when there is an MUE edit that’s being triggered by drug administration services, there is an underlying reason. The MUE limit on 96375 of 6 allows a new drug to be administered every four hours in a 24-hour period. See if the claims hitting the edit are related to long observation stays—it may be that the patient is staying in observation too long. Go back and see what the root cause is for why those numbers are getting that high.

Typically, when drug administration is billed correctly by date of service, we do not see MUE edits triggered, even when the patient comes in through the ED and stays overnight.

Editor’s note: Denise Williams, RN, COC, and Valerie A. Rinkle, MPA, answered this question on the HCPro webinar “NCCIs and MUEs: Solving Claims Edits.”