Primary Care Coding Alert

You may think intravenous (IV) hydration coding is just a matter of reporting 90780-90781, but that attitude will only dry out your revenue. You must know when to bill an E/M visit and how to navigate hospital admission coding if you want to receive optimal reimbursement for severely dehydrated patients.

FPs often send severely dehydrated patients to the hospital. However, many family practices are able to administer intravenous hydration within about one to three hours, says Shannon Joyce, MD, clinical faculty at St. Vincent Family Medicine Residency in Indianapolis.

For the first hour, use 90780 (Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour). Bill additional hours with add-on code +90781 ( each additional hour, up to eight hours [list separately in addition to code for primary procedure]). An add-on code is always performed in addition to the primary procedure and cannot be reported as a stand-alone code. Joyce also uses J codes for the supplies, such as J7030 (Infusion, normal saline solution, 1,000 cc), J7050 ( 250 cc) or J7042 (5% dextrose/normal saline [500 ml = 1 unit]), depending on the fluid and amount.

Because the physician must assess the cause of dehydration, you can also bill for an E/M visit, Joyce says. For example, suppose a patient presents with vomiting, diarrhea and dizziness. The FP examines her, takes an orthostatic blood pressure and determines she has gastroenteritis and is severely dehydrated. The physician puts the patient on IV hydration for two hours. Code this visit with 90780 and 90781 and the appropriate-level E/M code. This visit type usually warrants a level-three E/M, Joyce says.

"Technically, the physician can bill an E/M as well, if performing a separately identifiable service," says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C. But, she emphasizes, reimbursement for the E/M is carrier-specific. "Some payers query the office visit code whenever they receive a claim that has both a procedure and an E/M. They expect you to prove that you did something else."

Documentation is crucial: Write a good E/M note and make sure it is in a separate paragraph from the note about the hydration. The need for modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) also varies from carrier to carrier, Callaway says.

Some coders mistakenly use prolonged services codes 99354-99355 with 90780-90781. This is incorrect coding because both the IV hydration codes and the prolonged services codes are by definition time-based, so the two cannot combine.

Nor should you use the prolonged service codes instead of 90780-90781, unless the FP remains with the patient for the entire treatment. For 90780 and 90781, the physician must directly supervise the case but not necessarily be face-to-face with the patient. Prolonged services codes require face-to-face contact.

"Many private payers don't recognize prolonged services, and most patients requiring constant face-to-face contact would be sent to the hospital," Joyce says.

Sometimes, even after office hydration, the physician admits the patient to the hospital. For example, a diabetes patient comes to the office dehydrated after a bout of gastroenteritis, and the FP attempts office hydration. However, after several hours, the patient has persistent vomiting requiring admission.

In this scenario you can still bill for the in-office hydration. The physician time and supplies for the hydration are paid separately. Bill the hospital care code (99221-99223), not the outpatient E/M service. Include the work you did in the office when selecting the level of admission code. As long as you include your notes for the office hydration and evaluation, you can ethically use them to upcode the hospital admission.

Whether the patient is subsequently admitted has no bearing on whether you can bill the 90780 performed in the office, Callaway says. "Billable services are billable whether you admit the patient or not," she explains.

If the FP performs the intravenous hydration in a hospital setting, 90780 is not billable, Callaway says, because of the "under direct supervision" verbiage in the code definition. Medicare rules, which most private payers have picked up, do not allow such procedures to be billed when the site of service is inpatient the payers assume that a technician, not a physician, performed the service. The hydration fee is tied to the facility fee.

"Once the patient is admitted, I would only bill for professional services (99231-99233)," Joyce says. "After all, I wouldn't bring my own fluids over."