Billing and Coding Infusion, Injection and Hydration

Alexis Wilkinson CPC
Jan 15
4 min read

Updated: 3 days ago

Accurate billing and coding for infusions and injections starts long before you ever look at CPT codes. The process begins with understanding when the patient was admitted, where they were located, and what services were actually documented and administered.

This is the step-by-step workflow coders should follow.

Coding Infusion and Injection _Wearemedicalcoders

Step 1: Identify the Admission and Encounter Dates

Start by determining:

The date(s) the patient was admitted
Whether the patient was placed in observation or inpatient status
The exact time the observation or inpatient order was entered

This establishes the correct encounter and ensures charges are applied to the proper date and patient status.

Step 2: Verify Patient Location in Event Management

Next, go into Event Management in Epic.

Here, you confirm:

Where the patient was physically located
When the patient was in each location

This step is critical because infusion and injection charges must align with the patient’s documented location at the time the service was provided.

Step 3: Review Admission and Discharge Orders in Doc Review

Navigate to the Doc Review tab in Epic.

In Doc Review, you are looking for:

The admission order to identify the exact admission time
The discharge order to confirm the discharge time

These timestamps define the boundaries of the encounter and prevent charges from falling outside the billable window.

Step 4: Analyze the Medication Administration Record (MAR)

Once encounter timing and location are confirmed, move to the MAR.

Inside the MAR, you are specifically looking for:

IV infusions
IV pushes
Intramuscular (IM) injections
Subcutaneous (SubQ) injections

For IV infusions, documentation must include:

A clear start time
A clear stop time
The MAR is often messy and non-linear, especially for IV medications. Coders will commonly see multiple entries for the same drug, including start times, rate or dose changes, handoff and verification steps, pauses, restarts, and new bag documentation. These actions reflect clinical workflow, not separate billable services, which is why coders must evaluate the full timeline before assigning infusion or IV push charges. Find out more about the action in infusions and learn what it means to a coder.

Step 5: CPT Coding Infusion and Injection Rules

Use the MAR documentation to determine how each medication should be coded.

Hydration

Must be medically necessary to be billable
Routine fluids are not separately reportable

Infusions without a stop time

If an IV medication has a documented start time but no stop time, it is coded as an IV push, not an infusion

IM or SubQ injections

These are coded with CPT 96372

Step 6: IV Push Coding Rules

IV push services follow strict rules:

If multiple IV pushes of different drugs are given at the exact same time, only one IV push may be charged
If different drugs are given at least one minute apart, each IV push may be charged
If the same medication is given again less than 31 minutes after the prior dose, an additional IV push cannot be charged

Timing and drug distinction are key.

Why This Process Matters

Following this workflow ensures:

Charges align with patient status and location
Infusion time is accurately supported
IV push rules are applied correctly
Hydration is only billed when medically necessary
Claims withstand audits and payer review

Infusions and Injection Documention That is

Non-negotiable

This process forms the foundation of compliant infusion and injection charge capture.

• Physician's Order: A valid, signed order is required. It must specify the drug name, dose, route of administration (e.g., IV, IM), and frequency.

• Medication Administration Record (MAR): This log is the definitive source for what was given and when. It must include the drug name, dose, and route, and most importantly, the specific start and stop times for any infusion.

• Support for Medical Necessity: The documentation must justify why the service was needed. This can include a provider's notes describing signs and symptoms (like dehydration), abnormal lab results (like low potassium), or other clinical findings that warrant the treatment.

Best Practice: Always document exact "start" and "stop" times for all infusions. These times are non-negotiable for accurate, compliant coding.

With a solid understanding of the documentation required, we can now use that information to make our first and most important coding decision: identifying the 'initial' service based on a strict coding hierarchy.

Now if that wasn't confusing enough that only define individual services, let's explore how to code for multiple substances given during a single encounter.

Coding for Multiple Infusions: Sequential vs. Concurrent

When a patient receives more than one substance through the same IV line, you must determine if the administrations were sequential or concurrent.

Concept	Description
Sequential Infusion	This occurs when multiple different drugs are infused one after another ("back-to-back") through the same IV access point.
Concurrent Infusion	This occurs when multiple therapeutic drugs are infused simultaneously from separate bags through the same IV line. This code is not used if multiple drugs are mixed in the same bag.