Refresh Your IV Hydration Coding Knowledge

Infusion & Injection Reporting Hierarchy
Chemotherapy	Infusion
	IV Push
	Injection
Therapeutic, Prophylactic & Diagnostic	Infusion
	IV Push
	Injection
Hydration	Infusion

When multiple infusion and injection services are performed during the same encounter, the order in which they are administered does not determine the order in which they are reported. Instead, the hierarchical order determines which category of infusion is reported as the initial infusion service, as well as the order for all subsequent infusion and injection services. For example, a patient who is administered IV hydration, followed by chemotherapy infusion, and then a prophylactic injection (in that order) would be reported, based on the hierarchy, in the following order:

• Chemotherapy infusion 
• Prophylactic injection
• Hydration service

In this scenario, the hydration service, although performed first, is sequenced last based on the hierarchical structure of infusion and injection services. 

IV Hydration Service Qualifiers

There are several guidelines that must be adhered to when reporting IV hydration services, as follows: 

1. IV hydration requires prepackaged IV solutions. Some of the more commonly reported IV hydration services are listed below:

   1. Saline solutions
   2. D5W (dextrose 5% water) 
   3. Hypotonic solution
   4. Ringer’s lactate solution
   5. DW (distilled water)
      
      
2. Do not report IV hydration when other drugs have been mixed into the prepackaged saline solution essentially using the saline solution as a transportation medium instead of a treatment for dehydration or fluid volume loss. In this situation, the prepackaged saline solution is a supply cost only, reportable with a HCPCS code just like the drug that was mixed in with it. 
   
   
   1. For example, injecting potassium into the IV fluids for the purpose of treating an electrolyte deficiency, such as hypokalemia, is considered a therapeutic infusion service. This service would be reported with a therapeutic infusion code rather than an IV hydration code.
      
      
3. IV hydration services are therapeutic, designed to replace fluid loss, or “rehydrate” a patient suffering from fluid volume loss or dehydration and as such, the documentation should clearly paint a picture of the patient’s condition to support the hydration services such as:

   1. Symptoms that have led to or indicate dehydration such as: vomiting, diarrhea, dark yellow urine, headaches, dizziness, and muscle cramps 

      1. Nausea as a singular symptom does not indicate a loss of fluid volume, but nausea with vomiting could.Abnormal labs (e.g., elevated BUN, creatinine, glucose or lactic acid)
         
         
   2. Abnormal labs (e.g., elevated BUN, creatinine, glucose or lactic acid)
   3. Changes in vital signs coupled with symptoms
   4. Inability to drink fluids, coupled with symptoms or a timeframe that puts the patient at risk
   5. Physiological or psychological conditions that prevent fluid consumption with symptoms 

According to Medicare, aside from dehydration and fluid volume loss, there are other patient conditions that may support medical necessity for IV hydration services, such as: 

• Using hydration immediately before or after a transfusion
• Chemotherapy
• IV infusion or injection of drugs that could be toxic to the kidneys (nephrotoxic), including IV contrast, which is used in certain diagnostic procedures (e.g., MRIs).  

Be aware of those circumstances when a patient is immediately started on IV hydration upon presentation to the emergency department (ED,) but the medical record shows no evidence to support dehydration or any of the other circumstances listed above. In these circumstances, the IV hydration service is not medically supported by the documentation and would become nonbillable and bundled into the E/M encounter. 

IV Hydration Services Require an Order from a Qualifying Provider 

A qualifying provider must order and document the order in the medical record. Qualifying providers include physicians and nonphysician practitioners (NPPs). An order can be formally written out and signed, located within the treatment plan documented in the patient’s encounter notes, or documented by qualifying clinical staff (e.g., RN) as a verbal order received from the provider. When qualifying clinical personnel (e.g., RN) receive a verbal order, they document the exact order in the medical record along with the date and time received and the provider’s name, and they sign it in a legible manner. At this point there is a 48-hour timeframe in which the order must be confirmed in writing and signed by the ordering provider. 

Orders should always include be documented in the patient’s medical record and provide enough detail to support the service provided, such as: date of the order, substance (strength, quantity), route of delivery (e.g., IV push, IV infusion), ordering provider name and credentials, and a valid signature. Failure to meet the documentation requirements could lead to negative audit findings resulting in demands for repayment. 

Infusions Are Incident-To Services

IV hydration infusion is an incident-to service, meaning the service is performed by a qualifying clinical staff member while under the direct supervision of a physician/NPP. In the non-facility setting, physicians/NPPs often perform IV infusion services themselves, unless they have qualified staff authorized to do so. However, in the facility setting, these services are performed by nursing staff. Always check the scope of practice for your individual state to identify which clinical staff members may be authorized to administer infusions and injections under direct supervision. For example, while infusion services are not in the scope of practice for medical assistants, according to the AAMA, in some states their scope of practice may include administering certain injection services under the direction of a supervising physician/NPP. Registered nurses, according to the American Nurses Association (ANA) are licensed to perform infusion services. 

When IV hydration services are performed incident-to, the clinical staff member is responsible for documenting the service in the medical record in the same manner in which a physician/NPP would. They must adhere specifically to the order given by the physician/NPP and document exactly what they did for the patient such as: 

• Substance administered, including strength, dose, and lot number
• Method or route of delivery (e.g., IV push, IM injection) and rate of administration
• Location (e.g., right arm, left deltoid, right antecubital)
• Outcome or post-infusion/injection patient status (e.g., patient tolerated well)
• Start and stop times for each substance administered
• Performing staff member’s signature, legibly printed name, title, and date of signature 

How to Assign and Sequence IV Hydration Codes 

The following codes are used to report IV hydration services when administered therapeutically for the treatment of dehydration or fluid volume loss: 

• 96360 Initial service (31-60 minutes)
• 96361 Each additional 60 minutes)  (add-on (+) code) 

Code 96360 represents the initial hydration service lasting between 31-60 minutes as determined by the start/stop times documented in the medical record. If less than 31 minutes were documented, the service is considered unbillable and bundled into the greater service for the encounter. If more than 60 minutes is documented, 96361 may be eligible for reporting but only if at least 31 minutes beyond the initial 60 have been documented for a total of 91 minutes. Start and stop times MUST be documented in the medical record. A notation of total time will not suffice. When only the start times of each drug are documented, the service becomes ineligible for infusion services and may be reduced to IV push. Many otherwise reportable services are often rendered unbillable simply because both the start and stop times were not documented in the medical record. 

Note: The documentation must support the code description criteria for medical necessity, initial (primary code) versus each additional (add-on code), and time (start/stop). 

Initial Infusion Service 

A close look at all of the infusion codes in this section indicate each type of infusion service has both an initial and sequential code. The guidelines indicate that only one initial service code may be reported per patient encounter, unless there are two infusion sites. According to the infusion hierarchy table, if multiple types of infusions are performed, only a single initial infusion service is reported based on the hierarchy, and sequential or the add-on code is reported for the others. 

The following table includes the codes and times for both hydration and other therapeutic, prophylactic, or diagnostic injections. Although our focus is on coding IV hydration services, it is important to show how they are considered for reporting when administered alongside other infusions in the same encounter. 

IV Hydration Services		Therapeutic, Prophylactic & Diagnostic Infusion Services
Total Time (mins)	Code(s) & Unit(s)	Total Time (mins)	Code(s) & Unit(s)
31-90	96360 (1)	16-90	96365 (1)
91-150	96360 (1), 96361 (1)	91-150	96365 (1), 96366 (1)

 

Scenario 1: The patient was diagnosed with fluid volume loss from vomiting and diarrhea caused by a viral disease. She received IV hydration services with D5W. Start: 1:00/Stop: 2:30 for a total of 90 minutes. 

Codes: 96360 x 1 unit

Explanation: A total of 90 minutes of IV hydration services were reported and code 96360 accounts for 60 minutes with an additional 30 minutes remaining. To assign code +96361 would require a minimum of 31 minutes of IV hydration time (91 minutes total).  Code 96361 is for each additional 60 minutes of IV hydration infusion time beyond the initial 60 minutes from CPT code 96360, and the initial unit of +96361 is eligible for reporting once 31 minutes (or 91 total minutes) has been reached.

Coding Tip: If less than 30 minutes of IV hydration service is documented, the service is bundled into the E/M encounter and is not eligible for reporting. IV hydration cannot be reported as IV push. 

Correction Notice: There was an error in Scenario 1 which was corrected on August 15, 2024.

Scenario 2: The patient received IV hydration services using a package of normal saline. 

Start:10:02/Stop:12:13 or a total of 131 minutes 

Codes:  96360 x 1 unit
              96361 x 1 unit

Explanation: The full 60 minutes was reached for 96360, and for 96361 with 11 minutes remaining. As this 11 minutes is less than the 31 required to report an additional unit of 96361, the remaining 11 minutes is not reported. 

Scenario 3: The patient received IV hydration services for? Start: 8:00/Stop: 9:32 (total 92 minutes),  followed by therapeutic IV infusion of Rocephin 1 gram; Start: 10:48/Stop: 11:48 (total 60 minutes).

Codes: 96365 (1 unit), 96361 (2 units) 

Explanation: The infusion coding hierarchy indicates therapeutic infusions are sequenced before IV hydration services. As such, the initial infusion code will be one unit of 96365 as the time supports 60 minutes. The IV hydration will be reported as an add-on code (96361), as only one initial infusion code may be reported per encounter. Two units of 96361 are reported as 92 minutes were reported. 

Scenario 4: The nurse mixed a therapeutic drug into a bag of normal saline for infusion. Start: 11:04-:11:38 (total 34 minutes). 

Codes: 96365 (1 unit)

Explanation: These do not qualify as hydration services, as the saline solution was just being used as a transport medium for the therapeutic substance being administered. 

Non-Payable Infusion Services

• Flushing a line with normal saline between substances
• Saline used to keep a line open between substances
• IV hydration infusion services lasting 30 minutes or less
• Free-flowing hydration during chemotherapy/other therapeutic infusions
• Reporting hydration services as a concurrent infusion

Bundled Services

When a service not separately reportable because it is an integral part of the greater procedure, it is considered a bundled service. The National Correct Coding Initiative (NCCI), developed by Centers for Medicare and Medicaid Services (CMS) publishes NCCI edits that identify which service codes are bundled into others. While some services may not be reportable at all, simply because they do not meet the criteria of a hydration service for therapeutic purposes, others may not be reportable because they are bundled services. The following are some services which may be considered bundled:

E/M Services

E/M services performed on the same day as a procedure are not separately reportable unless the documentation supports a significantly, separately identifiable service was performed and not just the usual pre and post surgical care required for the infusion service. When the E/M service meets this criteria, it is reported with modifier 25 to override the NCCI edit and allow the E/M service to be paid. Medicare identiifes a new patient E/M as qualifying for modifier 25, as the decision to perform the surgery had to be made during the E/M encounter on that date. However, for established patients, it is possible the decision may have been made at a prior encounter and therefore the documentation must clearly identify that the decision to perform the infusion service was made during the encounter before it can become eligible for unbundling with modifier 25. 

Supplies/Procedures Integral to the Infusion

Services considered incidental to the infusion itself and bundled into the RVU include: local anesthesia, starting the IV, creating access to an indwelling IV, subcutaneous catheter or port, flushing the port at the conclusion of an infusion or to clear the line between infused substances, standard supplies such as tubing, syringes, and other supplies, and preparation of the infusion (mixing substances in with the saline solution or preparing a chemotherapy agent). 

Direct Supervision 

When IV hydration is performed by qualified clinical staff and the physician/NPP is providing direct supervision, the supervision is considered incidental to the service and not separately reportable as an E/M service. Incident-to services are reported under the provider’s NPI number, as if the physician/NPP performed the service themselves. 

Resources:

• American Nurses Association 
• AAMA-State Scope of Practice Laws 
• CMS Billing and Coding Hydration Services  
• CPT Code Book, 2022

About Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Aimee L. Wilcox is a medical coding, billing, and auditing consultant, author, and educator with more than 30 years of clinical and administrative experience in healthcare, coding, billing, and auditing. Medicine, including coding and billing, is a constantly changing field full of challenges and learning and she loves both. Aimee believes there are talented medical professionals who, with proper training and excellent information, can continue to practice the art of healing while feeling secure in their billing and reimbursement for such care.