Health Information Management

Examine IV hydration issue on RACs list for reviews

JustCoding News: Outpatient, November 18, 2009

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Some of the issues CMS has already approved for review under the Recovery Audit Contractor (RAC) permanent program are straightforward. For example, typically you can only bill for a once in a lifetime procedure once in a person’s lifetime (e.g., hysterectomy or appendectomy). However, the IV hydration issue is one that lends itself to confusion and in turn, inaccurate reporting.

Simply put, you can only bill one unit of service per patient per date of service for IV hydration CPT code 90760. (CPT code 96360 replaced code 90760 January 1, 2009.) This is currently an approved issue for all RACs except DCS Healthcare, the RAC for Region A.

Editor’s note: Access this Revenue Cycle Institute tool (CMS-approved RAC audit issues) to get the most up-to-date, comprehensive list of all the issues approved for review in each state.

Transfers can trigger reporting errors

Unfortunately, it is not always as simple as it may seem on paper. For example, sometimes the transfer of a patient from one department can inadvertently trigger reporting of multiple units for this initial service, says Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc., in Marblehead, MA.

Consider the following: A nurse in the emergency department (ED) starts IV hydration for a patient, which means coders can report one unit for that initial service. Then the physician orders observation services and the patient is moved to another area. Sometimes nurses administering services when the patient is in observation will mistakenly document an initial IV hydration service in an attempt to indicate this patient received the services during observation. This is an example of incorrectly reporting two units of this IV hydration code for one date of service. “You can only report one initial hydration service per date of service regardless of where you provided that service,” Mackaman says.

“In the ER, the rules are clear that whatever date of service you started the IV hydration, that’s the date of service you report even when the service spans over to the next date,” Mackaman says. If the ED nurse never terminated the service, then the IV hydration is simply an ongoing service even after the patient is referred to observation, she explains.

Mistakes in reporting IV hydration units often result from a lack of communication. Because you already reported one initial service code in the ED, you should report only the add-on code to reflect the ongoing IV hydration service in observation, Mackaman says.

“There has to be communication among the nursing staff members and coders, who may be responsible for sending through charges between units,” she says. “They have to understand that they can only report one initial no matter where it started.”

Multiple services can lead to confusion

Another potential reporting pitfall for IV hydration involves the fact that you may report only one initial service for the same IV site.

In a facility setting, there are specific guidelines regarding the hierarchy of these codes and which codes take precedence, says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CCDS, director of HIM and coding at HCPro, Inc.

Note the following hierarchy cited in the text preceding CPT code 96360 in the CPT Manual when referring to scenarios in which providers administer multiple infusions, injections, or combinations:

When these codes are reported by the facility, the following instructions apply. The initial code should be selected using a hierarchy whereby chemotherapy services are primary to therapeutic, prophylactic, and diagnostic services which are primary to hydration services.

“Notice that the bottom of this totem pole is hydration services,” McCall says. This often leads to confusion over coding “because many times, patients will get hydration as well as some other therapeutic infusion.”

Some coders make the mistake of reporting two initial services—one for the hydration and one for the IV infusion. However, coders should report the therapy infusion code first and then the add-on code for hydration when the required unit of time was met, McCall says.

The initial IV hydration code is meant to capture the initial work of setting up for the service, McCall says.

Also note that CMS does not recognize hydration as a concurrent service.

“If you start IV infusion of a drug and to administer that drug you set up a hydration bag at the same time, in that case you can’t report separately for hydration services,” McCall says.

Take caution with claims that involve modifier -59

When RACs perform automated reviews for IV hydration services, they will not request medical records and will examine only those claims for which the provider reports more than one unit of service for the same date of service. Although at this time RACs aren’t looking at claims with modifier -59 (separate and distinct procedure), they may once they begin conducting complex reviews, Mackaman cautions.

“Just because they’ve excluded modifier -59 claims at this point doesn’t mean that they can’t come back for complex medical reviews based on guidance for appropriate use of modifier -59,” she says. When reporting modifier -59, the documentation must support that this hydration service was separate and distinct from the initial procedure, Mackaman says.

Consider a scenario in which a patient comes to an outpatient, provider-based clinic in the morning and receives hydration services in the outpatient area. The patient returns home that morning. However, this same patient goes to the emergency room that night and receives IV hydration services again. This is an example of when it might be appropriate to report modifier -59, Mackaman says.

In addition to guidance in the CPT Manual and CPT Assistants, CMS has published guidance on the use of modifier -59 in MedLearn Matters article SE0715. You can also view additional guidance by accessing this National Correct Coding Initiative (NCCI) article.

MUEs contribute to murky dilemma

Part of the confusion is rooted in the fact that some medically unlikely edits (MUE) are unpublished, Mackaman says. “Providers don’t know what the MUEs are for infusion and hydration codes because CMS did not publish that information for us,” she says.

Also, CMS has provided contradictory guidance regarding the effect of modifiers when applied to HCPCS codes subject to MUEs, Mackaman says. The National Correct Coding Initiative Policy Manual for Medicare Services has indicated that there are no modifiers that will bypass MUEs.

However, CMS published frequently asked question #8736, which indicates that coders may report medically appropriate units of service in excess of an MUE on separate lines with an appropriate modifier. Each line with a HCPCS code subject to an MUE processes separately, allowing units in excess of the MUE to be paid when reported on a separate line (with a modifier).

If there is no MUE for the initial hydration code, then facilities could report units greater than one and potentially receive payment, Mackaman says. The missing link is that providers don’t know whether an MUE exists for these infusion and hydration codes. The bottom line is to not rely on your fiscal intermediary or Medicare Administrative Contractor to be your claims scrubber and catch these errors. The provider is responsible for the correct submission of claims based on the documentation and the coding and billing rules.

Editor’s note: Interested in learning more about modifier -59? Susan E. Garrison, CHC, CHCA, PCS, FCS, CCS-P, CPAR, CPC, CPC-H, and Peggy S. Blue, MPH, CPC, CCS-P, discuss specific, common scenarios for which it is appropriate to report modifier -59 in the June 23, 2009 HCPro audio conference, "Modifier -59: Manage Pre- and Post-Payment Audits to Reduce Denials."

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