Injections- Hydration
| Date: | June 13, 2024 |
| From: | Health Plan |
| To: | All Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) Providers and Hospitals |
| Type: | Regulatory |
| Subject: | Injections- Hydration |
| Business: | Medi-Cal Managed Care |
Through the new Claims Editing System (CES), Health Plan has identified the most significant changes and would like to share those with you.
Medi-Cal policies and guidelines require additional information submitted by providers to determine if billing requirements have been met for use of intravenous fluids for hydration as well as therapeutic, prophylactic, and diagnostic injections and infusions.
Hydration or Therapeutic/Prophylactic/Diagnostic Injections CPT Codes 96360, 96361, 96365, 96366 through 96370, 96375
CPT codes 96360, 96361, 96365 are reimbursable only when performed by a physician or by a qualified assistant under a physician’s direct supervision. Do not report code 96360 if performed as a concurrent infusion service. Hydration infusions of 30 minutes or less are not to be reported. The National Provider Identifier (NPI) number must be entered in the Attending field (box 76) or the Billing Provider Information and Phone number field (Box 33A) of the claim form for the claim to be reimbursed.
The maximum number of allowable units for CPT codes 96361, 96366 and 96370 is eight (8) units. Providers must submit documentation of medical necessity for quantities exceeding eight (8) units.
The maximum number of allowable units for CPT codes 96367 and 96375 maximum is three (3) units. Providers must submit documentation of medical necessity for quantities exceeding three (3) units.
Additional Sequential and Concurrent Infusion CPT Codes 96367 and 96368
Claims for codes 96367 and 96368, must include medical justification for concurrent or additional sequential infusion.
CPT Codes 96365 through 96368 Billing Restrictions
Codes 96365 through 96368 must not be used when billing for routine injections, intradermal, subcutaneous, intramuscular, or routine I.V. drug injections, chemotherapy and/or blood product components. Claims for these codes require documentation of physician’s direct supervision.
CPT Codes 96365 through 96375, 96377 and 96379 Billing Restrictions
CPT codes 96365 through 96375 must be billed “By Report” and require documentation of physician’s direct supervision. Do not report with codes for which I.V. push or infusion is an inherent part of the procedure, for example, administration of contract material for a diagnostic image study. Code 96377 must be billed “By Report”. Code 96379 must be billed “By Report” and requires an authorization and documentation of direct physician supervision.
| Direct Supervision Defined
Pursuant to Title 42 of the Code of Federal Regulations, section 410.32(b)(3)(ii), “direct supervision” means the physician must be immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed. |
By Report claims require the following information on the “By Report” attachment:
- Patient Name
- Date of Service
- Procedure number (list supplemental procedures, if applicable)
- Operating report and time, or procedure report. Each report must include a description of the actual procedure performed on the patient and the results of the procedure. Pro forma or “canned” reports are unacceptable.
- Estimated follow-up days required (if applicable)
- When billing unlisted procedures, also state the time involved, the nature and purpose of the procedure or service and how it relates to the diagnosis.
Place of Service/Facility Type Restrictions
Providers can only bill codes 96360, 96361, and 96365 thru 96368 with the following Place of Service/Facility Type codes:
| CMS1500 – Place of Service | UB-04 – Facility Type | Description |
| 11 | 79 | Clinic-Other (Office) |
| 53, 71, 72 | 71, 73, 74, 75, 76 | Clinic – Various |
| 24 | 83 | Special Facility – Ambulatory Surgery Center |
| 22, 65 | 13, 72 | Hospital – Outpatient/Clinic – Hospital Based or Independent Renal Dialysis Center |
| 23 | 14* | Hospital – Other (Emergency Room) |
| 42 | N/A | Ambulance (Air or Water) |
The facility type code is entered as the first two digits of Type of Bill field (Box 4).
These codes are not reimbursable when rendered to hospital inpatient, patients in a Nursing Facility Level A (NF-A), Nursing Facility Level B (NF-B), or at home because a nurse usually performs infusion therapy in these facilities.
*Facility type “14” must be billed in conjunction with admit type “1” to indicate outpatient emergency room services.
For more information on Injections: Hydration, please see:
For more information on Special Billing instructions, please see:
If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website WWW.HPSJ-MVHP.ORG
