EPIC:Determine Medical Necessity and Support- IV Access.

Determine Medical Necessity and Support-IV Access Within

This report provides a structured method for determining whether the use of multiple intravenous access sites is supported by documentation within the Epic electronic health record. The intent is to guide coders in evaluating documentation for medical necessity rather than clinical preference. This report is designed for charge capture specialist and compliance review and is not intended to guide patient care decisions.

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Scope and Data Sources Reviewed

The determination of multiple IV access necessity relies on a cross review of the following Epic documentation components

• Lines Drains and Airways records

• Medication Administration Record

• IV assessment

• Nursing documentation

• Order level comments

• Pharmacy notes Timing of medication administration

• Infusion activity

All conclusions must be based on documentation present within the medical record.

General Rules and the Dual Access Exception

Clarifying the appropriate application of Current Procedural Terminology codes for intravenous infusions, specifically addressing the nuanced conditions under which more than one "initial" infusion code may be reported within a single patient encounter

General Rule for “Initial” Infusion Coding

For IV infusion and IV push CPT codes, only one "initial" code is permitted per patient encounter, representing the primary infusion service based on the main reason for IV therapy

But of course like most guidelines, exceptions apply, particularly when medical necessity dictates simultaneous administration through separate IV access sites due to incompatible medications or critical patient conditions. When this happens a coder would assign an additional initial code with a modifier 59.

Knowing the Difference Between “Initial” vs. “New”

The term "initial" in the context of IV infusion coding refers to the initial iv access site established for therapeutic, empiric, or diagnostic purposes, regardless of whether it is the first medication administered.

Patients with Multiple IV Access Sites

While a patient may have multiple IV access sites, this does not automatically warrant the reporting of multiple initial infusion codes. The crucial distinction lies in whether each access site is medically necessary and actively utilized for concurrent, independent infusions that meet the criteria for initial coding.

Documentation Review Framework

Verification of Concurrent IV Lines

Epic documentation must show more than one IV line recorded as active simultaneously. This is verified through Lines Drains and Airways records showing different insertion sites with overlapping active times. Medication Administration Record entries must align with the same time window indicating use of more than one line.

If IV lines are documented sequentially without overlap the situation represents IV replacement rather than multiple access.

Assessment of Simultaneous IV Therapy

The Medication Administration Record should be reviewed for overlapping administration times. Evidence may include concurrent continuous infusions overlapping IV push or intermittent medications or two infusions running at the same time.

If no overlapping administration is present documentation support for multiple IV access is limited and should be considered insufficient unless other strong justification exists.

Medication Compatibility and Administration Requirements

Certain medications require separate or dedicated IV access due to incompatibility vesicant properties or infusion safety requirements. Documentation may be found in medication details pharmacy notes or order comments.

When Epic documentation indicates that medications cannot be co infused or require a dedicated line the need for multiple IV access is considered supported.

Continuous Infusion Requirements

Continuous infusions such as intravenous fluids anticoagulants insulin or vasoactive medications often require uninterrupted administration. If IV push or intermittent medications are administered during the same time period and documentation shows the infusion was not paused a second IV line may be necessary.

Epic documentation should demonstrate that the continuous infusion remained active during administration of additional medications.

IV Failure or Replacement Review

Documentation of infiltration occlusion pain or IV removal indicates line failure rather than concurrent access. In these cases the placement of a new IV represents replacement and does not support multiple IV access billing unless overlap is clearly documented.

Emergency or High Acuity Situations

In emergency or high acuity settings such as the emergency department trauma response or rapid clinical deterioration multiple IV access may be required for timely medication administration. Supporting documentation includes urgent medication timing nursing notes and acuity indicators within the chart.

Temporary concurrent IV access may be supported when urgency is evident and documented.

Documentation Standards and Audit Defensibility

To support multiple IV access the medical record must allow the reviewer to reasonably conclude that two IV lines were required at the same time due to medication administration needs. Acceptable support may be explicit or inferred through consistent timing and documentation across Epic modules.

Statements based solely on convenience staffing preference or patient vascular difficulty are not sufficient justification without additional supporting documentation.

Scenarios Requiring Only One Initial Code

In most cases, even if you have two bags running into two different arms, you still only bill one initial code and one concurrent or sequential code.

• Compatible Drugs: If drugs can be "Y-sited" (run through the same line), coding assumes they should be, and only one initial code is allowed.

• Failed Access: If the first IV site "blows" and a second one is started to continue the same medication, you cannot bill a second initial code. This is considered a continuation of the first service.

• Sequential Delivery: If one drug finishes and a second drug is started in a different arm, it is still coded as a "sequential infusion" (+96367), not a new "initial" (+96365).

  
  

Exception: When Two Initial Codes Are Permitted

The only time it is appropriate to bill two "Initial" codes (e.g., 96365 and 96365-59) is when the medical necessity for two separate peripheral sites is clearly documented.

Criteria for Two Separate IV Access Sites

To justify reporting a second initial code (with Modifier 59 or XS), the documentation must prove:

1. Simultaneous Administration: Both medications must be running at the same time.

2. Separate Anatomical Sites: Documentation must state the specific sites (e.g., "Left Hand" and "Right Antecubital").

3. Physical Inability to Share a Line: The drugs or fluids could not physically or safely be administered through the same site.

   
   

Criteria for Medical Necessity of Both Sites

Payers will generally only accept a second initial code if one of the following is documented:

• Chemical Incompatibility: The two drugs would cause a physical reaction or "precipitate" if they touched in the same tubing.

• High-Volume Requirements: In emergency or sepsis protocols where a patient requires massive fluid resuscitation that exceeds the flow rate of a single peripheral vein.

• Drug-Specific Protocols: Certain drugs (like some vasopressors or caustic medications) require a dedicated line that cannot be shared with any other substance for safety reasons.

  
  

Correct Coding Scenario Example

Scenario: A patient with sepsis requires a high-volume saline bolus (Hydration) and a simultaneous infusion of a therapeutic antibiotic that is chemically incompatible with the specific fluid additives.

• Code 1: 96365 (Initial Infusion - Antibiotic)

• Code 2: 96360-59 (Initial Hydration - Separate Site)

• Result: This is correct because the incompatibility and simultaneous nature require two separate access points.

  
  

Incorrect Coding Scenario Example

Scenario: A patient receives a 1-hour infusion of Drug A in the left arm. After it finishes, the nurse starts a 1-hour infusion of Drug B in the right arm because the patient's left arm was getting sore.

• The Error: Billing 96365 for Drug A and 96365-59 for Drug B.

• The Correction: Because they were not simultaneous, the second drug must be billed as +96367 (Sequential) despite being in a different arm.

  
  

Key Takeaways for Coders

• The "One Initial" Default: Always assume one initial code per day unless the medical record explicitly justifies a second site.

• Modifier Usage: Use Modifier 59 or XS on the second "initial" code only. Do not use it on add-on codes (which are already inherently separate).

• Check Compatibility: If the documentation doesn't explain why two sites were used, check drug-to-drug compatibility. If they are compatible, the second initial code will likely be denied.

• Time Matters: For concurrent infusions through separate sites to be "initial," they must happen at the same time. If they happen one after the other, they are sequential.