Intravenous Hydration - CA Service Specific Post-Payment Final Findings - JE Part A
Intravenous Hydration - CA Service Specific Post-Payment Final Findings
CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. Noridian's priority is to minimize potential future losses to the Medicare Trust Fund by preventing inappropriate Medicare payments. This is accomplished through provider education, training, and the medical review of claims. A post-payment review has been initiated based on data analysis.
This is to update providers of the claim review findings and closure of the file of Current Procedural Terminology (CPT®) code 96360 for California.
Summary of Findings
Since the initiation of the review, 296 claims were reviewed from September 25, 2020 through July 26, 2021 with an overall claim error rate of 64.9% and payment error rate of 59.5%. The breakdown of those findings are as follows:
- 104 claims were accepted
- 11 claims received correction for the following reason:
- Documentation did not support billed service was a primary infusion.
- Documentation did not support dates of service as billed.
- Documentation did not support CPT® code as billed.
- 7 claims were partially denied for the following reasons:
- Documentation did not support medical necessity of the services for all dates of services billed.
- Documentation did not support number of units billed for dates of service.
- 174 claims were denied in full for the following reasons:
- Documentation did not support medical necessity of the services billed.
- Documentation did not support 31 minutes or more of infusion time per the CPT® code descriptor.
- Documentation was not received timely in response to the additional documentation request (ADR).
If you are a provider that had claims involved in the review sample and disagree with a claim determination, the normal appeal process may be followed as directed on the Noridian website under Appeals or as directed in your claim remittance advice.
Education
| Paragraph Name | Paragraph Details |
|---|---|
| Hydration Coding Requirements | The Local Coverage Article: Billing and Coding: Hydration Services A54635 was created to assist with the proper use of the Current Procedural Terminology (CPT®) codes 96360 and 96361. Per the CPT® manual, these codes are intended to report an intravenous (IV) hydration infusion consisting of a pre-packaged fluid and electrolytes. These codes should not be used to report infusions of drugs or other substances. The hydration codes were developed to report the interventions provided to patient's presenting with dehydration and volume loss that require clinically necessary IV fluids. In order to bill the hydration codes, the overall documentation submitted must support a clinical assessment that describes symptoms warranting hydration such as signs and/or symptoms of dehydration, fluid loss, inability to ingest fluids or clear contraindication to oral intake, abnormal vital signs and/or laboratory studies. If the final clinical assessment does not support the medical necessity for IV hydration, CPT® 96360 and/or 96361 should not be billed. The local coverage article also addresses situations in which patient's receive IV fluids for the correction of dehydration or prevention of nephrotoxicity. The article lists two scenarios in which therapeutic fluid administration is medically necessary in these cases. They include:
|
| Documentation Supporting Infusion Units Billed | Per guidelines found in the Current Procedural Terminology (CPT®) manual, when reporting codes for which infusion time is a factor, use the actual time over which the infusion is administered. The CPT® manual includes descriptors and guidelines when billing codes for hydration, chemotherapy, infusion, or injections. In order to evaluate the actual time of a hydration or infusion/injection services, it is important that the medical record include either documentation of the total infusion time OR both the start time, when the infusion starts dripping, and the stop time, when the infusion stops dripping, to support the services billed. |
| Expectation of Correct Billing | Services provided by your facility are expected to be billed in compliance with CMS claims processing guidelines. Medical Review will continue to correct claims based on the submitted documentation if billing is found to be incorrect. Noted continued billing errors may be referred to the Provider Outreach and Education (POE) representatives for education on proper billing in accordance with CMS requirements. If a provider is consistently billing incorrectly, this may be highlighted for review and possible referral to the Unified Program Integrity Contractor (UPIC) for potential compliance or abuse issue. |
| Correct Coding | The Current Procedural Terminology (CPT®) Manual is a listing of descriptive terms and identifying codes for reporting medical services and procedures. The purpose of the terminology is to provide a uniform language that accurately describes medical, surgical, and diagnostic services, and thereby provides an effective means for reliable nationwide communication among physicians, patients, and third parties. The name of the procedure or service that most accurately identifies the service performed and documented in the medical record should be selected. Inclusion of a descriptor and its associated five digit identifying code number in the CPT® manual is generally based upon the procedure being consistent with contemporary medical practice and being performed by many physicians in clinical practice in multiple locations. It is the responsibility of providers to be familiar with the descriptive terms and identify the most appropriate and comprehensive CPT® codes for reporting medical procedures and services. The complete, descriptive documentation of all services rendered is absolutely necessary in order for a claim to be properly evaluated. Medical Review will continue to correct claims based on the submitted documentation if billing is found to be incorrect. |
| Timely Submission of Documentation and 569PPs | It is the responsibility of Medicare providers to submit all documentation requested on the additional documentation requests (ADR) within the allotted time frame. Noridian allows 45 calendar days for the medical records to be received per the ADR request for post-payment reviews. On day 46, if the medical records have not been received, the claim will be denied provider liable with reason code 569PP. If there is no documentation to complete the medical review (MR), services billed on the claim cannot be supported. A redetermination request should be submitted to Noridian within 120 days from the date of the 569PP denial. Contractors shall reopen the claim for review as long as all conditions are met. The determination made on the reopening claim has the potential to reverse non-covered dollars. For additional information, refer to Internet-only Manual Pub 100-08, Chapter 3, Section 3.2.3.8, 42 CFR 424.5(a)(6), and Social Security Act sections 1815(a), 1833(e) and 1862(a)(1)(A). |
References
View references used in review. Further educational opportunities may be found under Education and Outreach. If you are in need of an individualized education training event, contact the POE Department at mac@noridian.com. If you need coding assistance, please check your CPT®, HCPCS, ICD-10 books and your specific association.
Provider Action Required
File results and trending errors are being shared with all providers to assess compliance and billing practices if the service is provided within your facility. If your facility had claim documentation requested for this review, please refer to the individual result letter you received. You can also access individual determinations for claims that were requested from your facility by reviewing comments in either DDE or on the Noridian Medicare Portal (NMP).
Further provider action recommended includes:
- Provide education regarding errors noted to applicable staff members.
- Verify documentation supports medical necessity of Current Procedural Terminology (CPT®) code 96360.
Summary
This service specific post-payment file is now closed for CA and Noridian will no longer request documentation for this review. Noridian will continue to monitor data analysis and perform medical review for medical necessity and appropriate coding practices.
If you have any other questions, contact the JE Provider Contact Center at 1-855-609-9960.
