The information contained herein pertains to intravenous therapy services (except chemotherapy, which has separate instructions) performed at a hospital or other healthcare facility on an outpatient basis. This information does not apply to intravenous therapies administered in the emergency room.
Using the correct combination of codes is the key to minimizing delays in claims processing. Please ensure that revenue codes and procedure codes reflect the diagnoses and services rendered. Third-digit subcategories for the revenue code are included in the Official UB-04 Data Specifications Manual.
Commonly Billed Services
The matrix below depicts commonly billed services and acceptable code ranges that correspond to HMSA's claims processing requirements for intravenous therapy other than chemotherapy. The matrix represents a range of possible combinations and should not be viewed as comprehensive.
Administration
| Revenue Code | Description | Level of Code | Code | Description |
|---|---|---|---|---|
| 260 | Intravenous therapy: general classification | HCPCS | Q0081‑22 | Infusion therapy using other than chemotherapeutic drugs, per visit |
| 76x | Treatment/observation room | Although recommended by Medicare's ambulatory payment classification (APC), these codes are part of HMSA's all-inclusive rate and are not paid separately. |
Notes: HMSA payments for IV therapy vary, depending upon the type of therapy provided. To ensure that claims are processed without delay and that payment is correct, please include a narrative description in the remarks section (Form Locator 80) that describes the therapy being provided.
IV therapy should be billed using revenue code 260 and HCPCS code Q0081 with modifier code 22. Therapies may include, but are not limited to, the following:
- Hydration therapy (Please indicate the number of liters and whether the hydration solution contains additives.)
- Antibiotic, antiviral and antifungal therapy
- Desferal (deferoxamine mesylate) therapy, intravenous or subcutaneous
- Intravenous immune gammaglobulin therapy (IVIG). Precertification required
- Inotropic infusion therapy (e.g., Dobutamine, Dopamine)
- Diophosphonate (Aredia) therapy
- Miscellaneous IV administration, intermittent or continuous infusion
More than one therapy may be given to a patient on a specific date of service. In such a case, each therapy should be billed on a separate line. To indicate a second or subsequent therapy, use modifier SH or SJ as appropriate.
For example, when more than two therapies are rendered on a single day, the codes used would be as follows:
- 260 - Q0081-22
- 260 - Q0081-22, SH
Incidental Drugs and Supplies
Incidental drugs and supplies are used to deliver the service. These items are included in the administration fee and are not paid separately.
| Revenue Code | Description | Level of Code | Code | Description |
|---|---|---|---|---|
| 25x | Pharmacy | HCPCS | Use HCPCS codes that describe the services rendered. | |
| 27x | Medical/surgical supplies and devices | HCPCS | Use HCPCS codes that describe the services rendered. | |
| 290, 291 | Durable medical equipment (other than renal) | HCPCS | Use of durable medical equipment while in the facility is part of the administration fee. |
Drugs Requiring Specific Identification
Drugs requiring specific identification must be billed separately.
| Revenue Code | Description | Level of Code | Code | Description |
|---|---|---|---|---|
| 636 | Drugs requiring detailed coding | HCPCS | J1626 | Injection, granisetron hydrochloride, 100 mcg |
| J2430 | Injection, pamidronate disodium, per 30 mg | |||
| J3490 | Unclassified drugs. When unlisted/NOC (not otherwise classified) J codes are used, enter the corresponding National Drug Code (NDC) information in form locator 43 of the UB-04 |
Refer to Intravenous Therapy UB-04 Highlights for more information.
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform |