Health Information Management

Q/A: Reporting hydration with phlebotomy

APCs Insider, November 11, 2011

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Q: We provide IV fluids to our patients who undergo therapeutic phlebotomy procedures to replace fluid volume lost during the procedure. Should we report CPT® code 96360 (intravenous infusion, hydration; initial, 31 minutes to 1 hour) or 96361 (intravenous infusion, hydration, each additional hour) for the hydration with CPT code 99195 (phlebotomy, therapeutic [separate procedure])? Can you advise us?

A: Providers use therapeutic phlebotomy to reduce a patient’s total blood volume, decrease the number of red cells, or reduce high amounts of iron in the blood. The purpose of hydration is replacement of some of the fluid volume removed as the procedure is performed. Therefore, the service is integral to the therapeutic phlebotomy procedure.

The National Correct Coding Initiatives Policy Manual, chapter 11, states: "Services integral to performing the phlebotomy (e.g., CPT codes 36000, 36410, 96360 – 96376) are not separately reportable.”

Based on this documentation and the presence of an NCCI edit that requires coders to append modifier -59 (distinct procedural service) to 96360 when reported with 99195, you should not report hydration service when it is provided as part of a therapeutic phlebotomy procedure.

Editor’s note: Andrea Clark, RHIA, CCS, CPCH, president of Health Revenue Assurance Associates, Inc., in Plantation, FL, answered this question.



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