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Documentation of hydration

  1. #1
    Location
    New Windsor, New York
    Posts
    1,183
    Default Documentation of hydration
    Medical Coding Books
    I am having a disagreement with some members of our hospital coding team about the necessary documentation to code hydration (96360-96361) for the facility.

    Typically, there is an order by the physician for hydration. There is documentation of start and stop times and the appropriate code and charge for 96361 is entered if there is a push or infusion of another drug (see CPT Assistant May 2010) or 96360 if no other durg is infused and then 96361 for additional hours of hydration. Time documentation is very good, so that is not the issue.

    The issue is that the hospital coders are saying that a bolus order of saline or DS5 by the physician is not sufficient documentation for billing the hydration. My though is why not - we have a physician order documented, the time of hydration is documented and if the diagnosis meets medical necessity per LCDs, payor rules, etc, then these hydration services should be coded and billed.

    I would love to hear other opinions on this and what other documentation could the hospital coders be looking for. Thank you in advance for any opinions shared.

    Lance Smith, MPA, COC, CPMA, CEMC, RHIT, CCS-P, CHC, CHPC

    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY

  2. #2
    Location
    New Windsor, New York
    Posts
    1,183
    Default Just moving on up...to the east side...
    Since I am still in disagreement with the hospital coders, moving up to see if I can get any other opinions...

    Lance Smith, MPA, COC, CPMA, CEMC, RHIT, CCS-P, CHC, CHPC

    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY

  3. #3
    Default
    Found this online: http://medical-coding-carers.blogspo...on-coding.html hope it helps.

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