Health Information Management

Determine the purpose and medical necessity of hydration before reporting it

APCs Insider, January 18, 2008

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QUESTION: When reporting a code for hydration, we know that documentation of medical necessity supports billing the service. However, should the physician document "hydration, dehydration" in the order to support medical necessity, or can he or she document this information in the notes, progress notes, ER report, etc.? If the physician documents nausea and vomiting and orders .9% normal saline at an appropriate rate and length, is this enough to show the clinical indicators for hydration or CPT codes 90760 and 90761?

ANSWER: According to the American Medical Association, CPT does not specify documentation requirements related to hydration. If a physician orders fluids, medical necessity would be evident based on the clinical scenario that the physician describes in his or her documentation.

Therefore, documentation and medical necessity support for the hydration/therapeutic infusion service is associated with the evaluation service performed by the provider on the same day. Typically, this involves the clinical assessment that gives describes the dehydration, the patient's inability to intake fluids with the physical assessment, and/or vitals and/or laboratory testing/results supporting this status. Documentation of the service itself (i.e., hydration, therapeutic infusion) occurs simply by ordering and recording the provision of the hydration with specific start and stop times.

It is important to distinguish the medical necessity of hydration (which is billable) from the appropriateness of hydration lines that the physician inserts to keep the vein open, as the latter is not separately billable. Note that in 2008, CPT clarified that hydration of 30 minutes or less is not separately billable, even if it is medically necessary and the physician documents it.



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