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

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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.

 

CodeDescription
S9373, S9374, S9375, S9376, S9377Hydration Therapy
99601Nursing Care


 

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. 

 

 
Rev#:Date:Nature of Revision:
   
   
2.0 (v5)10/06/2022The following code to the Claims Filing Information section: S9375

 
Rev#:Date:Nature of Change:
1.004/03/2006Removed outdated sample claim form and updated example to reflect that providers no longer need to bill the per diem in seven-day increments. Also removed information about initial, continued and extended therapy, as these definitions no longer apply. Other modifications were made due to major changes in reimbursement methodology that were effective January 1, 2006.
1.104/05/2006Changed title of document from "Hydration Therapy, Prolonged Home Intravenous for Adults and Adolescents - Administrative Information" to "Home Prolonged IV Hydration Therapy for Adults and Adolescents."
1.211/12/2010Removed reference to cpt code 99602
1.311/17/2010Added: S9374, S9376, S9377
1.412/12/2012Added the following note at the bottom of the page: "Note: This document contains ICD-9 diagnosis codes.  In accordance with DHHS’ final ruling, claims for services rendered on or after the compliance deadline of October 1, 2014 must be submitted with ICD-10 diagnosis codes.  The diagnoses listed in this document will be updated with the appropriate ICD-10 codes no later than April 1, 2014."
1.503/18/2014Added "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)." and removed "Note: This document contains ICD-9 diagnosis codes.  In accordance with DHHS’ final ruling, claims for services rendered on or after the compliance deadline of October 1, 2014 must be submitted with ICD-10 diagnosis codes.  The diagnoses listed in this document will be updated with the appropriate ICD-10 codes no later than April 1, 2014."
1.611/06/2020Title change from Home Prolonged IV Hydration Therapy for Adults - Administrative Information to Home Intravenous (IV) Hydration Therapy for Adults - Administrative Information. Added content section to the top of the page and a link to the medical policy at the bottom of the page for more information.
1.712/01/2020Removed the following row from the table:
Identify hydration solution using NDC numberJ3490 and NDC number
Added content: For hydration solution
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.
1.803/11/2021Added the sentence: For specialty pharmacies, please refer to the Billing for Injectable Drugs (Non-Vaccines) article.
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