Home Intravenous (IV) Hydration Therapy for Adults – Administrative Information

Precertification is not required. HMSA reserves the right to perform retrospective review using the above criteria to validate if services rendered met payment determination criteria. The following documentation must be kept in the patient’s medical record and made available to HMSA upon request:

1. For terminally ill patients, documentation indicating that the treatment is palliative and in lieu of hospitalization.
2. For all other patients:
   1. Documentation supporting clinical and/or laboratory evidence of hypovolemia prior to initiation of IV hydration. Examples include:
      1. Clinical: reduced urine output, decrease in blood pressure, increase in heart rate, orthostatic vital sign changes, weight loss and change in mental status.
      2. Laboratory: increased urine specific gravity, abnormal serum osmolality or electrolytes and elevated BUN or creatinine.
   2. For prolonged use, documentation supporting that patient is responding to IV hydration and that the medical condition is unresolved, and the patient is unable to tolerate adequate oral or enteral hydration.

Special Considerations

• Hydration therapy may not be billed as a multiple therapy (e.g., may not be billed concurrently with enteral or parenteral nutrition therapy).
• In the event of an unexpected discontinuation of therapy, payment will be made for up to a five-day supply of previously dispensed fluids.

Claims Filing Information

Please use the codes listed below when submitting claims for hydration therapy.

For Hydration Therapy

Identify the hydration salutation using the specific HCPCS code when available. Use the unlisted HCPC code (J3490) and NDC number only when a specific HCPC code is not available. For specialty pharmacies, please refer to the Billing for Injectable Drugs (Non-Vaccines) article.

Example

The patient is experiencing hypovolemia and electrolyte imbalance (ICD-9: 276.52; ICD-10: E86.1) due to irritable bowel syndrome (ICD-9: 564.1; K58.0). The attending physician has prescribed two liters of dextrose 5 percent - lactated ringers solution a day for five days.

The provider bills the per diem for hydration therapy on the first service line.

S9373 x 5 units

The hydration solution is billed on the second service line, using HCPCS code (J3490) and the NDC code for the drug. The units (column 24G) are calculated as follows:

• One liter of fluid is equal to 1,000 milliliters.
• Two liters a day times five days equals 10,000 milliliters.

J3490 NDC: 00264-7751-00 x 10,000 units

For information, please refer to the Intravenous (IV) Hydration Therapy for Adults medical policy.

Revision History