Health Information Management

Q&A: Documentation for hydration

HIM-HIPAA Insider, March 13, 2012

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QUESTION: We have a question in regards to hydration that we are trying to figure out. Does the physician specifically have to state in his or her documentation that the IV is for hydration purposes or can a coder figure it out through critical thinking and using the process of hierarchal injection/infusion coding when reading the record?

For example, X IV fluids are being used for an antibiotic and after the antibiotic, the IV fluids continue at 125/hr for hydration.
 
Does the physician need to document "for hydration"? Our physicians do not want to write that. Do you have any good advice on this?
 
ANSWER: CPT® guidelines state that codes 96360–96361 are used to report IV hydration by the infusion of “pre-packaged fluid and electrolytes (e.g., normal saline, D5-1/2 normal saline + 30mEq KCl/liter).” There is an exclusion to reporting these codes when the purpose is to keep an IV line open prior to, or immediately after, a therapeutic infusion. The administration of antibiotics is therapeutic.
 
Therefore, you must have documentation as to the reason the saline is being administered. Is it for hydration (include codes 96360 and, if appropriate, 96361) or just to keep the line open related to administrations of antibiotics (in which case you do not report either code 96360 or 96361)?
 
Editor’s note: Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CHA, of Safian Communications Services in Orlando, FL, answered this question in the February 21 issue of JustCoding.com.



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