office visit AND IV hydration

[rroblin]

I work specifically with ICD-9 codes only, so this is out of my field of expertise. A patient seeing his PCP, in addition to the reg office visit, requires IV hydration over 3-4 hr duration. This is being administered in the office. So- we have an office visit AND in house IV administration over 3-4 hrs. Please help with any ideas of appropriate coding.

 

[mack80]

Hydration with E/M

See the parenthetical guidelines in the CPT book under Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions etc, just prior to 96360 for IV infusion for hydration. You can bill a separate E/M code with appropriate modifier if a significant, separately identifiable office or other outpatient E/M service is documented as performed. This is a CCI edit - the E/M code is a subset to the IV hydration, but is modifier eligible (if appropriately documented).
If a separate E/M service is documented, you would bill the appropriate E/M level with the correct modifier (for example) 99212-25, then 96360 x 1 unit for the 1st hour of IV hydration, with 96361 x 2 (additional 2 hours, total of 3) or 96361 x 3 (additional 3 hours, total of 4) depending on the time documented in the records.

 

[rroblin]

IV hydration

Thank you so much for your response. Not having worked with CPT codes since my CPC exam 4 yrs ago, I am quite in the dark.

Robin

 

[khc123]

Further clarification

See the parenthetical guidelines in the CPT book under Hydration, Therapeutic, Prophylactic, Diagnostic Injections and Infusions etc, just prior to 96360 for IV infusion for hydration. You can bill a separate E/M code with appropriate modifier if a significant, separately identifiable office or other outpatient E/M service is documented as performed. This is a CCI edit - the E/M code is a subset to the IV hydration, but is modifier eligible (if appropriately documented).
If a separate E/M service is documented, you would bill the appropriate E/M level with the correct modifier (for example) 99212-25, then 96360 x 1 unit for the 1st hour of IV hydration, with 96361 x 2 (additional 2 hours, total of 3) or 96361 x 3 (additional 3 hours, total of 4) depending on the time documented in the records.

Can you also bill 36000 for Needle insertion?
I do not bill for the normal saline but have been told it is in fact billable (ie: J7030) do you know if this is correct?