Patient getting infusion therapy

IV hydration therapy is a key service where documentation remains a serious concern in terms of compliance. A recent Targeted Probe and Educate (TPE) review exposed the importance of conducting internal documentation review and providing crucial education for correct coding. By looking at some of the conclusions, CPT coders and healthcare compliance professionals will be more equipped to overcome hydration therapy documentation obstacles for future success.

Denial Revelations Warrant a Documentation Reckoning

Medical review shed some major light recently on the problems with documentation. Findings from The Jurisdiction F, Part A Medical Review Department Targeted Probe and Educate (TPE) review examined two codes:

CPT® 96360Intravenous infusion, hydration; initial, 31 minutes to 1 hour
CPT® 96361Intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure).

The quarterly edit effectiveness results from January 1, 2020, through March 31, 2020,  revealed several top denial reasons including:

  • Documentation does not support medical necessity.
  • Documentation does not support IV hydration was provided per coding definition.
  • Documentation does not support number of units billed.

Understand that insurance coverage and payment is restricted to conditions requiring medically indicated fluid replacement. The Targeted Probe and Educate findings of the same payer conducted a subsequent review of 100 claims with dates of service from September 25, 2020, through February 12, 2021. The results should startle compliance professionals. The second review of claims produced an overall claim error rate of 67% and payment error rate of 70.8%. This is a wake-up call following the first round of findings. The findings from round two include:

  • 33 claims were accepted as complying with payer requirements.

One claim was partially denied for documentation that did not support the medical necessity of services on all dates of service billed and the documentation did not support the total number of units billed. Based on the findings, our experts suspect that this was an observation claim. 66 claims – 66% of the audited claims – were denied in full for two reasons:

  • Documentation did not support medical necessity of the services billed
  • The payers request for additional documentation was not met in a timely manner.

The consequences to a facility are serious. Think about the impact to the facility if a facility was faced with a similar post-payment audit that identified a 66% error rate compounded with a 70% payment error rate. Not only are the results alarming, but this is the second warning notification the facility has received spotlighting the medical necessity for documentation. The ultimate lesson is crystal clear, if the final clinical assessment fails to support the medical necessity for IV hydration, codes 96360 and/or 96361 should not be billed.

The hydration codes were originally created to report the interventions provided to patients presenting with dehydration and volume loss that require clinically necessary IV fluids. In order to bill the hydration codes correctly, the overall documentation must support a clinical assessment that describes symptoms warranting hydration such as signs and/or symptoms of dehydration including:

  • fluid loss,
  • inability to ingest fluids or clear contraindication to oral intake,
  • abnormal vital signs,
  • and/or laboratory studies.
Guideline Knowledge

It is a known fact that the guidelines for documentation, coding, and billing of hydration therapy have been published and available since 2006. Billing providers, therefore, have had 15 years to create strategies and adapt documentation templates, educate clinical staff, and teach coding and billing guidelines. Even more, payer articles provide straightforward guidance on hydration therapy as a prophylactic service for the prevention of nephrotoxicity.

This applies to the prevention of nephrotoxicity immediately before or after transfusion, chemotherapy or administration of potentially nephrotoxic medications; and/or immediately before or after IV contrast infusion for a diagnostic procedure in a patient with renal insufficiency.

This is a patient with a documented history of renal insufficiency that is scheduled for a radiology procedure requiring IV contrast. Understand that this is distinctly different than a department protocol of administering fluids to any patient aged 50 or greater prior to receiving IV contrast. Fluid administration based on department protocol is a cost of doing business that is not supported by documentation of patient-specific medical necessity – but – is targeted to a population of individuals based on age.

When time is a factor of CPT code assignment use the actual time over which the infusion is administered. So, what must the medical record include? The medical record must include either documentation of total infusion time, or both the start time, when the infusion starts dripping, and the stop time, when the infusion stops dripping. If coding is based on documentation of total infusion time – be certain that sufficient documentation is present to support a calculated time – this means total volume infused and rate of infusion which should allow the calculation to support the total time for infusion.

Explore more knowledge of IV hydration services and documentation. Master everyday challenges and find further insights by utilizing our Hospital Outpatient Infusion Services: 2022 Reimbursement & Compliance Update webcast on-demand. Our leading experts Robin Zweifel, BS, MT (ASCP), and Tiffani Bouchard, CCS, walk you through pressing challenges related to outpatient infusion services and educate you on essential compliance topics that could impact your facility this year and beyond.

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