Noridian Medical Review (MR) has observed errors in billing for intravenous (IV) hydration services. This article is to assist in better understanding the proper usage of the below codes for billing and coding purposes.
CPT Definition:
- 96360: Intravenous Infusion, hydration; initial, 31 minutes to 1 hour
- 96361: Intravenous Infusion, hydration; each additional hour (list separately in addition to code for primary procedure)
These codes are intended to report a hydration IV infusion consisting of pre-packaged fluid with or without electrolytes (e.g. normal saline, D5-1/2 normal saline+30mEq KCl/liter) and are not used to report infusion of drugs or other substances.
Hydration Defined:
The hydration codes 96360 and 96361 were developed to report specific therapeutic interventions undertaken when a patient presents with dehydration and volume loss requiring clinically necessary intravenous fluid.
- The necessity for hydration should be supported in the medical record.
Documentation would include but is not limited to:
A. Clinical assessment, typically on the same date of service, of the patient’s anticipated fluid needs. This can be demonstrated from the patient’s history, clinical examination, and pertinent laboratory testing to support the need for IV hydration therapy as reasonable and necessary for the patient’s treatment or diagnosis.
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- Documentation of the assessment should describe symptoms warranting hydration, such as those associated with dehydration, the inability to ingest fluids or clear clinical contraindication to oral intake, abnormal fluid losses, abnormal vital signs, and/or abnormal laboratory studies, such as an elevated BUN, creatinine, glucose or lactic acid.
- Nausea itself does not necessarily indicate fluid volume depletion nor support necessity of fluid repletion.
B. These codes are not intended to be reported/billed by the physician or other qualified healthcare professional in the facility setting, as these codes most likely represent facility charges with applicable reimbursement through the respective fee schedule. However, in the physician office setting (example, Place of Service 11), the physician may report these codes when the physician’s clinical staff or the physician administers the fluids.
C. For facility reporting, an initial infusion is predicated on using a hierarchy.
D. When administering multiple infusions (e.g. IV fluids and subsequent IV chemotherapy infusion on same date of service), only one primary infusion code should be reported for a given date, unless protocol requires that two separate IV sites must be used.
E. Hydration cannot be reported concurrently with any other infusion or drug administration service.
F. The definition of infusion time is inherent and presented in the guidelines for these codes. In other words, a minimum time duration of 31 minutes of hydration infusion is required to report the service.
G. Consequently, infusion time is calculated from the time the administration commences (i.e. the infusion starts dripping) to when it ends (i.e. the infusion stops dripping).
H. In accordance with Medicare Reasonable and Necessary Criteria, (Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.2), the benefit must meet but does not exceed the beneficiary’s medical need, and as such, IV fluids should be avoided if not deemed clinically necessary.
- For example, although some conditions may warrant intravenous rehydration, if documentation supports the same benefit could be achieved by oral hydration, IV hydration would not be considered reasonable and necessary.
- However, it is understood that there are clinical scenarios in which the patient’s need for hydration cannot wait for oral trials, even if an option. The intent should be understood within the body of documentation.
I. Examples of Additional Payable Scenarios:
- If therapeutic fluid administration is medically necessary:
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- for the correction of dehydration or prevention of nephrotoxicity immediately before or after transfusion, chemotherapy, or administration of potentially nephrotoxic medications.
- immediately before or after IV contrast infusion for a diagnostic procedure in a patient with renal insufficiency.
J. Non-payable scenarios : The following infusion circumstances do not represent hydration and should not be reported using any of these CPT codes:
- If the sole purpose of the intravenous fluid is to maintain patency (i.e. keep open) of an IV line prior to, during, or subsequent to a chemotherapeutic or therapeutic infusion, or transfusion.
- If used as “maintenance” IV therapy replacing normal sensible and insensible fluid losses, not losses associated with a pathological condition.
- When the purpose of the infusion is to accommodate a therapeutic IV piggyback through the same IV access to safely infuse the agent (e.g. IV fluids infused simultaneously with drug administration).
- If the fluid is used as the diluent to mix the drug (i.e. the fluid is the vehicle in which the drug is administered).
- Hydration that is integral to the performance of a surgical procedure to establish an initial and underlying IV flow for a diagnostic or therapeutic infusion is not separately billable (e.g. IV fluids administered preoperatively, intraoperatively, and/or postoperatively).
- Routine administration of IV fluids, pre/post operatively while the patient is NPO for example, without documentation supporting signs and/or symptoms including those of dehydration or fluid loss is not supported as medically necessary.
- Infusion of IV fluids with electrolytes for the purpose of treating an electrolyte deficiency (e.g. hypokalemic patient being treated specifically for low potassium level for which 20 mEq of KCL is added to an IV fluid).
In conclusion, the main question that should be asked when considering billing for 96360 and 96361 is whether IV hydration is an appropriate, accepted standard of medical practice as a diagnostic or specific treatment for a beneficiary’s condition,is one that meets, BUT does NOT exceed the beneficiary’s medical need, and cannot be met with oral hydration.
Note: It is understood that depending on the clinical scenario, upon presentation, an IV line may be established, fluids initiated, labs drawn and sent for evaluation and imaging completed with examinations. Although it may be reasonable to start fluids upon presentation, in order to bill the IV hydration codes, the medical necessity for the hydration services must also be supported. If the final clinical assessment does not support intravenous hydration was necessary for beneficiary’s medical needs, hydration codes should not be billed
References:
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CPT Assistant Coding Update: Infusion/Injection services; February 2009; Volume 19, Issue 2, pages 17-21).
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CPT Assistant Coding Clarification; Facility reporting-Multiple Infusions (Codes 96360, 96361, 96365-96367); December, 2011; Volume 21, Issue 12, pages 3-5).
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National Institute for Health and Care Excellence (NICE) Guidelines; Intravenous Fluid Therapy in Adults in Hospital; December, 2013.
- 2020 CMS NCCI Policy Manual for MC Services; Ch. 11, Medicine E/M Services CPT codes 90000-99999 and corresponding CMS NCCI edits.
5. Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.2 – Reasonable and Necessary Criteria