Editor’s Note: Cutting through the red tape to make certain that you get paid for every dollar you earn has become more difficult than ever, particularly in our current climate of health care reform and ICD-10 transition. The ACEP Coding and Nomenclature Committee has partnered with ACEP Now to provide you with practical, impactful tips to help you navigate through this coding and reimbursement maze.

Question: What do I need to document to ensure appropriate reimbursement when a patient receives intravenous fluids?

Answer: Incredibly, some payers are down-coding or, worse, denying facility charge payment for ED evaluations that do not clearly document the medical necessity for intravenous fluid administration.¹ Documentation of nausea, vomiting, or diarrhea alone may be insufficient to justify intravenous hydration.

To ensure appropriate reimbursement, emergency clinicians should include medical documentation supporting the need for intravenous hydration. The ED note should include the standard history, physical examination, and medical decision-making elements that support the need for intravenous hydration. Common examples include physical examination or diagnostic testing results indicating acute dehydration, abnormal fluid losses, unstable vital signs, or systemic inflammatory response syndrome criteria (ie, fever, dry mucous membranes, skin tenting, delayed capillary refill, tachypnea, hypotension, or tachycardia) or abnormal laboratory testing such as an elevated white blood cell count, blood urea nitrogen and/or creatinine, glucose, creatine phosphokinase, sodium, calcium, or lactate. Additional supporting documentation may include the patient’s inability to tolerate oral hydration, need for rapid intravascular volume expansion (ie, hypotension, sepsis, or shock), or treatment of other causes of abnormal fluids losses (eg, heat-related illness, thermal burns, or medication-related over-diuresis). 

Dr. Barrett is associate professor of emergency medicine at Vanderbilt University Medical Center in Nashville, Tennessee.

Reference

1. Local coverage article: hydration services (A52732). Noridian Healthcare Solutions website. Accessed March 13, 2019.