By: Ashley L. Brandon, MBA, RHIA, CCS, and Cheryl E. Servais, MPH, RHIA

 

Preparedness offers the best results, and hospitals and physicians are encouraged to be proactive rather than reactive in their approaches. Conducting internal audit reviews to evaluate areas of concern, establishing baseline policies and procedures to ensure proper coding and billing, and commencing investigative actions for problems found provides a solid foundation as providers adjust to the Centers for Medicare and Medicaid Services (CMS) recovery initiative.

 

The appointed RAC for Region C, Connolly Consulting, recently announced a list of seven issues they intend to target initially. This list includes IV hydrations. For this service, significant code changes and corresponding coding and billing guidelines were put into place effective Jan. 1, 2006. Drug administration codes G0345 - G0363 were replaced by CPT codes 90760 - 90779. These codes again were replaced Jan. 1, 2009 by 96360 - 96549, including codes 96360 - 96361 for IV hydration. These changes can be a source of billing errors. In addition, problems can occur with use of codes and supporting documentation. As presented below, an internal audit can help a provider identify areas that might be vulnerable to RAC audits.

 

With the scope already defined (CPT codes 96360 and 96361 for records billed in 2009, and codes 90760 and 90761 for records billed from Jan. 1, 2006 - Dec. 31, 2008), the first step of an internal audit would be gathering a sufficient sample of IV hydration cases. The size of the sample depends on the volume of these services, their complexity, the number of providers and whether there is any suspicion or prior evidence of issues with billing IV Hydration services (all of these factors serve to increase sample sizes). No fewer than 30 records should be reviewed. The sample should include old cases (cases billed between Oct. 1, 2006 and Dec. 31, 2009), recently billed cases (Jan. 1, 2009 - July 31, 2009), and pre-billed cases. By selecting these three types of cases, the provider can determine if the coding/billing rule changes effective Jan. 1, 2006 were correctly implemented in old cases, whether the coding/billing rule changes effective Jan. 1, 2009 were correctly implemented in recently billed cases and whether the most recent cases are being coded/billed correctly.

 

The criteria for the audit should reflect  the focus of the recovery audit reviews: payments on services for which providers failed to provide documentation when requested or submit sufficient documentation to support claims, payments for services that are not coded properly and payment errors including claims paid twice due to duplicate submission.

Documentation

 

Since coding and billing of IV hydration solely is dependent on accurate and legible medical record documentation, this should be the starting point of internal audits. Clear notation should exist for actual start and stop times for each bag, the route of administration, and whether a flush or hydration is performed. If only a flush (clearing of lines) is performed, the procedure is not coded unless the flush occurs with medication (referred to as an "IV push"). An IV push may be coded. Documentation such as "over 1 hour" in an order; 600cc infused with no start or stop times; medically unlikely amounts of medications versus route (e.g. "NS 400cc per hour flush");  "Initial line (INT) removed/hep-lock discharged"; administration times that are marked through and/or illegible; and times recorded that do not make sense (i.e. start time 10:09 with stop time 9:19) cannot be coded and thus should not be billed.  The lack of clear documentation initially could result in lost revenue or the issuance of a RAC demand letter for repayment of the reimbursement received.

 

As referenced in AMA's CPT 2009, IV hydration infusions typically require direct physician supervision for purposes of consent, safety oversight or intra-service supervision of staff. The physician should document his/her supervision of IV hydration procedures performed by nursing staff.

Coding and Billing

 

After documentation has been reviewed, internal auditors should turn the focus to the specifics of IV hydration coding and billing guidelines.  If the aforementioned coding changes were not implemented in a timely manner, charge masters and/or charge sheets might have incorrect codes listed. Internal auditors should review these areas to be sure all changes were made. Claims billed with improper codes may result in incorrect reimbursement.

 

Using the same audit sample, auditors should validate the following for each case (based on coding guidelines taken from AMA-CPT 2009, which have remained unchanged since 2006):

 

• Only one "initial" service code [96360] may be reported per patient per day unless protocol or circumstances require that two separate IV sites be used.