Intravenous Hydration - WY Service Specific Post-Payment Final Findings - JF Part A
Intravenous Hydration - WY 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 Choose an item..
This is to update providers of the claim review findings and closure of the file of Current Procedural Terminology (CPT®) code 96361 for Wyoming.
Summary of Findings
Since the initiation of the review, 74 claims were reviewed from October 23, 2020 through March 1, 2021 with an overall claim error rate of 62.2% and payment error rate of 68.2%. The breakdown of those findings are as follows:
- 28 claims were accepted
- 1 claim received correction for the following reason:
- Documentation did not support date of service billed.
- 2 claims were partially denied for the following reason:
- Documentation did not support the total number of units billed.
- 43 claims were denied in full for the following reasons:
- Documentation did not support medical necessity of the services billed
- Documentation did not include an infusion start and/or stop time to support services 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 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. |
| Documentation to Support Medical Necessity | The practitioner that orders a service must maintain documentation to support medical necessity for that service in the beneficiary’s medical record. It is the responsibility of the provider submitting the claim to maintain documentation that is received and that it reflects the information received from the ordering practitioner. The submitting provider may request additional information from the ordering practitioner to support the service billed is reasonable and necessary as laid out in the Social Security Act 1862. Upon receipt of the Additional Development Request (ADR), the billing provider must submit documentation of an order for the service, which includes information to identify and contact the ordering practitioner, to verify appropriate completion of the order and services billed. For additional information on record keeping supporting medical necessity of billed claims, refer to 42 Code of Federal Registry (CFR) section 410.32. |
| Correct Billing Units for Administration | Per Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual (MCPM), Chapter 4, Section 230.2, providers are expected to report administration according to the Current Procedural Terminology (CPT®) code descriptors, CPT® instructions, and correct coding criteria. Only one initial hydration administration service should be reported per access site, including services that span more than one calendar day. When billing CPT® codes for additional hour(s) of infusion it is important to note the infusion start and stop time to correctly bill units. |
| 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. |
| Physician Order | An order is a communication from the treating practitioner for medication to be given. The order for the medication must include the medication name, dose, route and frequency. The patient’s name must be on the order form along with the practitioner’s signature, date and time. The order must be legible. When a medication is given, the nurse must administer as ordered. If any part of the order is missing or incorrect the nurse should contact the provider for clarification and document the new order. For additional information, reference Internet Only Manual (IOM), Publication 100-08 Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.2 and 3.3.2.4. |
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 WY 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
