Hydration is taking in fluids to replace water in the body lost through expiration, urination, or sweat. Most individuals remain hydrated by drinking fluids throughout the day. However, when an individual is dehydrated, it may be necessary to replace fluids via an infusion.
When an infusion for hydration is ordered, medical necessity must be met. Often, dehydration is the diagnosis but other conditions such as acute kidney failure, hypotension, or electrolyte imbalance can also be indicators of the need for hydration.
Hydration codes (96360 and 96361) are assigned for administration of pre-packaged fluids and electrolytes according to CPT. Examples include normal saline and D5-1/2 normal saline + 30mEq KCl/liter. Do note that if other drugs or substances are infused, those CPT codes for hydration no longer apply.
If the fluid is being administered only to keep the line open, this does not constitute hydration. Also, if it is being used to dilute a drug that is being administered or is used to run along with chemotherapy or other therapeutic treatment, that is not considered hydration.
When hydration is administered before or after chemotherapy or other therapeutic treatment to prevent toxicity, then the hydration codes may be assigned. Be aware that based on the hydration codes listed below, there is a time requirement that must be met to assign the code. Hydration cannot be reported if the infusion time is 30 minutes or less. In order to assign the add-on code of 96361 after the first hour, more than 30 minutes must pass. This means the total time that could result in the initial hydration service would be from 31-90 minutes. At 91 minutes, code 96361 can be added for the second hour.
96360 Intravenous infusion, hydration; initial, 31 minutes to 1 hour
+96361 each additional hour
It is permissible to code for continuation of hydration that is initiated at a different facility with the patient being transferred to your facility. However, two points to remember: medical necessity must still be met, and if the IV hydration is only to keep the line open, it cannot be coded. If the continuation of the IV is medically necessary, you would begin the start time from the patient’s arrival and continue until the IV is stopped. The Medicare claims Processing Manual in Chapter 4 states the facility should report an “initial” infusion code with additional codes assigned as appropriate when this situation occurs.
Now, light has been shed on hydration.
About the Author
Dianna Foley, RHIA, CHPS, CCS, CDIP, is an HIM professional with over 25 years of experience. She earned her bachelor’s degree from the University of Cincinnati and holds RHIA, CHPS, CDIP, and CCS certifications from AHIMA, along with being an AHIMA-approved ICD-10-CM/PCS trainer. Dianna has held many positions in HIM and is now an independent coding consultant. She previously served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna is an AHIMA-published author and has volunteered with AHIMA on projects including certification item writing, certification exam development, coding rapid design, and most recently has served on AHIMA’s nominating committee. She is a presenter on coding topics at the national, state, and regional levels and serves as OHIMA’s Education Coordinator. Dianna mentors new AHIMA members and also provides monthly educational lectures to coders and clinical documentation specialists.
