Intravenous Hydration - NV Service Specific Post-Payment Final Findings - JE Part A
Intravenous Hydration - NV 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 Nevada.
Summary of Findings
Since the initiation of the review, 75 claims were reviewed from October 26, 2020 through March 31, 2021 with an overall claim error rate of 54.6% and payment error rate of 74.6%. The breakdown of those findings are as follows:
- 34 claims were accepted
- 1 claims received correction for the following reason:
- Documentation did not support service was rendered on date of service billed.
- 40 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.
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. |
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 errrors 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 NV 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.
