Wiki Hydration diagnosis requirement

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lhoot

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Good Afternoon,
Need some clarification on hydration administration coding. Can hydration be coded when there is no documentation stating the fluid administration is for hydration or if there is no diagnosis that would make hydration medically necessary?

Is hydration coded strictly based on the type of fluid being administered?

Thank you,
Laura
 
This would be a question for you to put to your manager or employer. Normally it is outside the scope of coders' work and training to make a determination as to whether or not any particular service is medically necessary because that is something that can only be done by a clinician. Some organizations may have internal guidelines about this, but there is not general coding guideline that I'm aware of that instructs that you should not code the service when a particular diagnosis is not present in the record.
 
My intended meaning is that the coder's role is to report, as accurately as possible, what services were performed according to the documentation in the record. It is not a coder's role to make a decision to exclude the reporting of some services based on an independent assessment that those services were not medically necessary - that is, unless your employer has agreed and given you the direction to do so.

There a good article in CPT Assistant from December 2011 that I'd recommend which I think would help clarify what hydration is and I think you might find helpful. It's too long to post the complete article here, but I've copied one section below which lists only four specific situations when hydration should not be reported - I'd just note that it never says hydration should not be reported based on a diagnosis:

The following infusion circumstances do not represent hydration and should not be reported using any CPT code:
• when the purpose of the infusion was to accommodate a therapeutic IV piggyback through the same IV access as a free-flowing IV to safely infuse the agent;
• when the fluid was used as the diluent to mix the drug (ie, the fluid is the vehicle in which the drug is administered);
• when the fluid is used to "keep open" the IV line prior or subsequent to another infusion; and
• when IV fluids are allowed to continue to run during the administration of the chemotherapy or therapeutic agent.
 
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