Knowledge Base Article

The summer heat is brutal these days. Everyone is looking for ways to beat the heat – staying inside in air conditioned comfort, jumping in a pool or under a sprinkler, and drinking lots and lots of water. But there are conditions and illnesses that result in dehydration at any time of the year where infusion of fluids is needed for treatment. What is required by Medicare in order for hydration services to be covered?

A couple of weeks ago, the Wednesday@One included an article about the July 2015 Medicare Quarterly Provider Compliance Newsletter. The Compliance Newsletter mentioned Recovery Auditor findings for hydration services lacking medically necessary diagnoses required by a Novitas Local Coverage Determination (LCD). At Medical Management Plus, we receive numerous questions related to hydration services, so this week I offer some guidance for hydration services based on the Novitas LCD, another LCD and three coverage Articles from various Medicare Administrative Contractors (MACs).

CPT instructions require the administration of a hydration infusion of more than 30 minutes in order to allow the coding of hydration as an initial service. Hydration of 30 minutes or less is not separately billable. This means hydration must last at least 31 minutes in order to bill it. If there is no documented stop time, the duration of the hydration infusion is unknown and should not be billed.

There must be a practitioner’s order for hydration therapy and documentation of the reason a patient needs hydration in the medical record.

Hydration for the following reasons is not considered medically necessary therapeutic hydration and is not covered by Medicare.

• Hydration to maintain vascular access/vessel patency is not covered.
• Fluids used solely to administer drugs is considered incidental hydration and not separately billable.
• Administration of fluids with blood transfusions or between chemotherapeutic agents to flush lines is not separately billable.

Covered indications for hydration services vary between the different coverage articles and LCDs:

• Palmetto’s Article (A53402) simply states hydration must be medically reasonable and necessary for a clinical condition that warrants hydration.
• Noridian’s Articles (A53857 and A50359) states, “Routine administration of IV fluids without documentation supporting signs and/or symptoms including those of dehydration or fluid loss is not supported as medically necessary.”
• Novitas’s LCD (L32738) indicates coverage for clinical manifestations of dehydration or volume depletion and in conjunction with chemotherapy. Hydration with chemotherapy is covered only when the infusion is prolonged and done sequentially (done hour(s) before and/or after administration of chemotherapy), and when the volume status of a beneficiary is compromised or will be compromised by side effects of chemotherapy or an illness.
• Cahaba’s LCD (L32290) lists four different medically necessary reasons for hydration:
• Documented volume depletion,
• In conjunction with chemotherapy (same restrictions as Novitas policy),
• Some endocrine conditions such as hypercalcemia, and
• As an adjunct to the treatment of hypotension.

There are a few additional restrictions in some policies other than those already mentioned:

• Cahaba and Novitas LCDs state that rehydration with the administration of an amount of fluid equal to or less than 500 ml is not reasonable and necessary.
• Cahaba also claims rehydration should only take a few hours, so the medical necessity of hydration lasting beyond 12 hours must be supported by documentation.
• The Noridian articles do not specify a certain rate of infusion but do clarify that to qualify as medically necessary hydration, the rate of infusion should support performance of this service for rapid replenishment.

If your MAC jurisdiction has a coverage policy for hydration services, please read it carefully to learn all of the indications and limitations of coverage. If your MAC does not have a policy that addresses hydration, the guidelines in the policies referenced here may provide some guidance for your hospital. Continue to monitor your MAC’s draft and new policies for any future requirements for hydration services.