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May 10, 2012

Correct Coding for Hydration Administration

Adapted from the AHA Coding Clinic, Volume 12; Number 1; First Quarter 2012

Hydration is defined as the replacement of necessary fluids via an IV infusion which consists of pre-packaged fluids and electrolytes. Hydration services are reported by using CPT codes 96360 (initial 31 minutes to 1 hour) and 96361 (each additional hour). IV fluids reported for hydration lasting 30 minutes or less is not reported using infusion codes.

For hydration services to be reported using CPT codes, the hydration services must be medically necessary. Examples of hydration services that may be medically necessary

Services that would not be considered medically necessary hydration:

Factors to consider when choosing appropriate CPT code selection:

Clinical Scenarios

  1. A patient is seen in a facility because of dehydration due to continuous nausea with vomiting. She is given a prepackaged solution of 1,000 cc’s of D5 ½ NS with 20 mEq KCL added to the bag (prepared by the pharmacy). The hydration is administered for an hour and 15 minutes. CPT code 96360, Intravenous infusion, hydration; initial, 31 minutes to 1 hour, would be reported for this encounter because there was no other intravenous infusion service performed during this encounter and the primary reason for the encounter was to administer the fluids and electrolyte(s) due to fluid loss from the patient’s continuous nausea with vomiting. The additional 15 minutes would not be reported due to the hydration services not being greater than 30 minutes past the initial hour.
  2. A patient arrived in the emergency department febrile, and dehydrated with a suspicious chest x-ray indicating possible pneumonia. The patient received an intravenous hydration infusion over six hours of Lactated Ringers as well as an infusion of Vancomycin over 1 hour. How would the hydration and administration of Vancomycin be reported? The medically necessary hydration would be reported with six units of 96361 and the infusion of antibiotics would be reported as the primary infusion with one unit of 96365.
  3. A 55 year-old diabetic female is brought to the emergency department due to acute altered level of consciousness. Blood glucose level initially is 42 mg1dL. The patient is promptly administered dextrose 50% (D50) 25g IV push for the altered level of consciousness at 08:29 am. Her blood glucose at 08:37 is 219 mgl dL. What is the correct CPT code for the D50? An IV push code would be used for the D50 since length of infusion time is not documented and the D50 is of a therapeutic (not hydration) nature.
  4. A patient was seen for low potassium level. He received a one hour bolus of intravenous fluid mixed with potassium for treatment of his low potassium level. What would the correct CPT code be for this encounter? 96365, infusion, for therapeutic, prophylactic or diagnostic purposes; initial; up to one hour. Since the potassium bolus is targeted at the treatment of the patient’s low blood levels, the infusion becomes therapeutic as opposed to hydration.

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