Dr. Hospitalist

“Infusion Privileges” a Simple Answer to Complex Issue

I have a couple of questions based on the following scenario: hospital infusion center treating patients referred by physicians who are not members of hospital staff and don’t have hospital privileges. Since they are not credentialed at the hospital, they cannot give orders for infusion treatment for their patients. And they are not interested in applying for membership and hospital privileges. First, is it OK for the referring physicians to talk to our hospitalist of the day and give an infusion treatment order? Second, what CPT code would the hospitalist use for just writing an infusion treatment order—and can they bill the service?

—Glena Loyola

Dr. Hospitalist responds:

The alternate site infusion therapy market has exploded in the U.S. in the past 25 years. Most of this surge has been driven by increased emphasis on cost containment and the desires of patients to resume their usual lifestyles while recovering from illness. Most recent estimates show that these services represent approximately $9-$11 billion a year. Although the cost is substantial, it is far lower than the cost of inpatient treatment.

Many hospitals have infusion centers, both as revenue-generating ventures and to provide a service for their patients without admitting them to the hospital. Initially, most centers focused on oncologic medications; most now provide a variety of infusion services and therapies. Having clinical staff, prescribing physicians, and pharmacists under the same roof, or in the same healthcare system, should lead to better communication, which is key when administering these specialty drugs. The center at my hospital is of average size, and it seems there are at least one or two medical emergencies there every month. I can imagine the wasted time and lives lost in situations where a full cadre of emergency staff was not immediately available.

The processes and procedures developed by hospital administrators to allow physicians to administer these medications are highly variable. When the centers first came on the scene, most of the prescribing physicians were practicing oncologists and active members of the medical staff. While oncologists still make up the largest group utilizing these centers, rheumatologists, cardiologists, and endocrinologists also are active participants. As these clinicians have aged, and as the services, as well as the variety of infusions, have expanded, hospitals have needed alternate staffing models to keep up.

My CMO created specific “infusion privileges” for health system physicians working on alternate campuses. This privilege allows them to write for the medications but does not give them core privileges like most courtesy staff designations. There is no associated hospital call or ED coverage requirement, and no quality monitoring is needed with this “special” designation. We did consider having our hospitalist write the orders for these docs, but there were many reasons not to go that route—most importantly the logistics and our current HM program’s bandwidth.

The situation you describe, in which physicians call in and give infusion orders to another physician/hospitalist, is the one I believe is most fraught with problems. The potential for prescribing error is very high. Plus, the multiple downstream opportunities for the patient’s care to be compromised are myriad. Because the consequences of a medication error with many of these infusions can be catastrophic, most institutions (including ours) limit who can prescribe them to those specializing in that field. Many also require physicians to use computerized physician order entry, which has been shown to reduce medication errors, for these agents.

The billing requirements for infusion centers and prescribers are very complex and were last globally consolidated in May 2004. CMS annually updates using National Correct Coding Initiative Edits, with which most coders are familiar. The CPT code is tied to the infusion or type of infusion that is given and even incorporates the amount of time it takes to administer. Prior to 2004, the codes incorporated practice expense as well as malpractice relative value units (RVUs), but zero physician RVUs. Since then, a lot has changed. Although a physician can usually bill for services using E&M codes, most require face-to-face time to be allowable. If you would like to bill independently as a prescriber for your services, I recommend you sit down with your coders and decide if it’s feasible.

Should Unaffiliated Physicians Have Infusion Privileges?