General

General Question for the Week of March 30, 2020

General Compliance Question of the Week

Question:

What are the documentation requirements to bill for hydration?

Answer:

To bill for hydration, the physician order must support the therapy with the medical indication for it (e.g., the sign, symptom, or disease the therapy will treat). Such documentation might include notations of the sign or symptom of severe nausea and vomiting, treatment for a patient who presents with an electrolyte balance, or another diagnosis supporting the therapy. Clinical documentation should also indicate the fluid administered, volume, and rate for infusion.


This question was answered in our Coding Essentials for Infusion & Injection Therapy Services. For more hot topics relating to infusion services, please visit our store or call us at 1.800.252.1578, ext. 2.

CPT© copyright 2020 American Medical Association (AMA). All rights reserved.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

CPT is a registered trademark of the American Medical Association.