Intravenous Hydration - WA Service Specific Post-Payment Final Findings - JF Part A
Intravenous Hydration - WA 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 Washington.
Summary of Findings
Since the initiation of the review, 299 claims were reviewed from October 23, 2020 through May 18, 2021 with an overall claim error rate of 54.2% and payment error rate of 60.5%. The breakdown of those findings are as follows:
- 137 claims were accepted
- 4 claims received correction for the following reason:
- Documentation supported the incorrect intravenous administration code was billed for the services that were rendered.
- 5 claims were partially denied for the following reasons:
- Documentation did not support medical necessity for all dates of service billed.
- Documentation did not support total infusion time or both infusion start and stop times to support services rendered.
- Documentation did not support the total number of units billed
- 153 claims were denied in full for the following reasons:
- Documentation was not received timely in response to the additional documentation request (ADR).
- Documentation did not support medical necessity of service billed.
- Documentation did not support billed services as being rendered.
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 A52732 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 Services Rendered | Under section 1833(e), Title XVIII of the Social Security Act (SSA) states, "no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period." No Medicare payment can be paid for claims that lack the necessary information for processing. Medicare claims will be allowed to process, when there is sufficient documentation in the patient’s records to verify the services were performed and were medically necessary and reasonable for the medical condition. Justification for the service may be documented in the physician’s clinic or hospital progress notes and/or laboratory results. If there is no documentation, or insufficient documentation to support the service, then Medicare considers the service was not rendered. Services will be denied without the necessary documentation to support services were rendered as billed. |
| 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. |
| 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 WA 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 JF Provider Contact Center at 1-877-908-8431.
