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If a patient is receiving an IV infusion for hydration therapy and the stop time is not documented in the medical record, how should the service be coded?
A minimum of 31-minutes must be documented for hydration therapy to be deemed a billable service. When a clock time is not entered in the medical record for the stop time the alternative is to calculate a total infusion time based on total volume infused and rate of infusion.1000cc infused at a rate of 250cc/hour = 4 hours. If it is not possible to determine start and stop time or total infusion time the administration of fluid would not be a billable therapeutic service.
This question was answered in our annual Hospital Outpatient Infusion Services: Reimbursement & Compliance Update webcast. For more hot topics relating to infusion services, please visit our store or call us at 1.800.252.1578, ext. 2.
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