IV Hydration Documentation and Coding Could Be Vulnerable to RAC Audits Part 1 - Page 2

    • On rare occasions, a patient can have two initial IV hydration procedures if, for example, the IV in the left arm blows out or has complications and another IV is started in the right arm. Clear documentation of start and stop times is a must for both IV services. Notation of  the reason(s) for the failure of the first initial hydration must be stated in the record. Additional documentation must describe the second initial hydration procedure in the other arm.
    • The time for the first initial hydration service must be indicated as 31+ minutes. If the initial hydration started at 9:00 and stopped at 9:30, the provider cannot bill for this service! The second initial hydration can be coded only if it goes beyond 31 minutes. If neither the first nor the second initial hydration lasts longer than 31 minutes, neither one should be coded or billed.
    • If a second "initial" administration code is appropriate, the code should be listed with modifier 59 appended.

  • For all IV Hydrations, start and stop times must be documented for proper coding and/or billing.

  • For hydration infusion intervals of greater than 30 minutes that go beyond one-hour increments, each additional hour is coded with 96361. No modifier is required.

  • IV Hydration codes should be billed with chemotherapy codes only if the hydration is given before or after the chemotherapy (if chemotherapy is given simultaneously with an IV hydration, the provider should not bill for the IV hydration). Look at claims that contain a Chemotherapy CPT code together with an IV hydration code for documentation of start and stop times in the record.

  • IV Hydration codes should be billed with Therapeutic Infusion codes only if the hydrations are given before or after the therapeutic infusion (if both infusions are given simultaneously, the provider should not bill for IV hydration). Look at claims that contain a Therapeutic Infusion CPT code together with an IV hydration code for documentation of start and stop times in the record.

  • IV hydrations ARE NOT coded and/or reported with blood transfusion codes, regardless of when the IV hydration is administered.

    Charge Process Audit

    The audit sample should be reviewed further in collaboration with charge entries on the claims to ensure that there is no duplication of charges from improper coding of services (i.e. duplication of codes on one claim). If this is occurring, the provider should review its charging processes to ensure that IV hydration charges aren't being captured on the floor (e.g. by the charge nurse), followed by retrospective capture by the medical record coder, resulting in double billing of the same service.


    Internal audits can provide excellent insight into a facility's and/or physician's practices, drawing attention to those  areas of concern that can be addressed successfully prior to external corrective action. Again, this can be achieved by first thoroughly examining the medical record documentation used to code, followed by validating whether coding guidelines are being followed, and finally comparing coding summaries and charge entries to avoid double billing. This proactive approach allows for potential liabilities to be determined and corrected; additional education to be provided where needed; revisions of policies and procedures to be made were necessary; overpayment to be returned with supporting documentation and explanation for the refund; and appeals to be submitted for facility underpayment (if found within 30 days of discharge) or in response to RAC demand letters with supporting documentation and explanation.




    American Medical Association. 2009.  Current Procedural Terminology, 2009 edition. Chicago: AMA


    Ingenix.  2008. Recovery Audit Contractor Audit High Risk Areas. USA

    ED. NOTE: Seven, CMS approved audits for Region C are expected to be approved for other Region C states including Florida, New Mexico and Colorado in the next several weeks. Our four part series will help you understand three major audit issues - Blood Transfusion, IV Hydration and Hospital Outpatient Rehab. We conclude our series with an analysis of the physician risk in the RAC Process. Next Wednesday, "RACs and Blood Transfusions," by Carla Engle, MBA.

    About the Authors


    Ashley L. Brandon, MBA, RHIA, CCS, is an Internal Coding Audit coordinator for Precyse Solutions, LLC.  Prior to joining Precyse she acted as a Corporate DRG Coordinator for a network of 23 facilities nationwide.  She has more than eight years of experience in health information management specializing in coding, reimbursement, and other business related functions.  In her position at Precyse Solutions, Ms. Brandon supports the Precyse Solutions Compliance Program by performing inpatient, ambulatory surgery, emergency room, outpatient, and E/M management coding audits on new hires and, on an annual basis, on all other coding colleagues.  She mentors new colleagues as needed.  In addition, she performs MS-DRG reimbursement audits, data quality/accuracy audits, physician services audits, and compliance audits. Ms. Brandon provides educational services to colleagues as well as, training and/or other services as requested by client hospitals.


Cheryl E. Servais, MPH, RHIA, has more than 25 years of experience in Health Information Management. In her position at Precyse Solutions, Ms. Servais' responsibilities include planning, designing, implementing and maintaining corporate-wide compliance programs, policies and procedures, and updating them to accommodate changes in federal and other regulations. In addition, she oversees training and development programs related to ethics, compliance and patient privacy; develops and chairs compliance and privacy advisory committees at the Executive and Board levels and takes an active role in professional organizations.