If a patient is receiving IV Infusion for hydration and the stop and start time is not documented in the medical record, how would we code that service?
It is important that infusion times are documented. CPT guidelines specifically state that infusions of 15 minutes or less are to be coded as an IV push. If a patient is receiving an IV Infusion for hydration and the stop time is not documented in the medical record, the documentation would only be able to justify an IV push. If the time can be determined you would code accordingly. For additional information on infusions, please reference Pub 100-04, Chapter 4, Section 230 “Billing and Payment of Drugs and Drug Administration located at http://www.cms.hhs.gov/manuals/downloads/clm104c04.pdf.
It is important that infusion times are documented. CPT guidelines specifically state that infusions of 15 minutes or less are to be coded as an IV push. If a patient is receiving an IV Infusion for hydration and the stop time is not documented in the medical record, the documentation would only be able to justify an IV push. If the time can be determined you would code accordingly. For additional information on infusions, please reference Pub 100-04, Chapter 4, Section 230 “Billing and Payment of Drugs and Drug Administration.
Related Questions
- If a patient is receiving IV Infusion for hydration and the stop and start time is not documented in the medical record, how would we code that service?
- What is the time period for viewing my patients medical record online through the refPortal program?
- What amount of time can the Connector Luer Lock (C35 or C45) safely stay on the patient’s IV line?
