Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
018x Hospital - Swing Beds
021x Skilled Nursing - Inpatient (Including Medicare Part A)
022x Skilled Nursing - Inpatient (Medicare Part B only)
023x Skilled Nursing - Outpatient
028x Skilled Nursing - Swing Beds
071x Clinic - Rural Health
077x Clinic - Federally Qualified Health Center (FQHC)
083x Ambulatory Surgery Center
085x Critical Access Hospital
Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Note: The contractor has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual Publication 100-04, Claims Processing Manual, for further guidance.
0250 Pharmacy - General Classification
0258 Pharmacy - IV Solutions
0260 IV Therapy - General Classification
0263 IV Therapy - IV Therapy/Drug/Supply Delivery
045X Emergency Room - General Classification
076X Specialty Services - General Classification
CPT/HCPCS Codes
Group 1 Paragraph: Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
Group 1 Codes:
96360 Hydration iv infusion init
96361 Hydrate iv infusion add-on
J7030 Normal saline solution infus
J7040 Normal saline solution infus
J7042 5% dextrose/normal saline
J7050 Normal saline solution infus
J7060 5% dextrose/water
J7070 D5w infusion
J7120 Ringers lactate infusion
ICD-9 Codes that Support Medical Necessity
Group 1 Paragraph: Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 96360, 96361, J7030, J7040, J7042, J7050, J7060, J7070 and J7120:
Covered for:
Group 1 Codes:
250.80 DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED
275.42 HYPERCALCEMIA
276.0 HYPEROSMOLALITY AND/OR HYPERNATREMIA
276.50 VOLUME DEPLETION, UNSPECIFIED
276.51 DEHYDRATION
276.52 HYPOVOLEMIA
458.9 HYPOTENSION UNSPECIFIED
535.00 - 535.01 ACUTE GASTRITIS (WITHOUT HEMORRHAGE) - ACUTE GASTRITIS WITH HEMORRHAGE
535.10 - 535.11 ATROPHIC GASTRITIS (WITHOUT HEMORRHAGE) - ATROPHIC GASTRITIS WITH HEMORRHAGE
535.20 - 535.21 GASTRIC MUCOSAL HYPERTROPHY (WITHOUT HEMORRHAGE) - GASTRIC MUCOSAL HYPERTROPHY WITH HEMORRHAGE
535.30 - 535.31 ALCOHOLIC GASTRITIS (WITHOUT HEMORRHAGE) - ALCOHOLIC GASTRITIS WITH HEMORRHAGE
535.40 - 535.41 OTHER SPECIFIED GASTRITIS (WITHOUT HEMORRHAGE) - OTHER SPECIFIED GASTRITIS WITH HEMORRHAGE
535.50 - 535.51 UNSPECIFIED GASTRITIS AND GASTRODUODENITIS (WITHOUT HEMORRHAGE) - UNSPECIFIED GASTRITIS AND GASTRODUODENITIS WITH HEMORRHAGE
535.60 - 535.61 DUODENITIS (WITHOUT HEMORRHAGE) - DUODENITIS WITH HEMORRHAGE
535.70 - 535.71 EOSINOPHILIC GASTRITIS, WITHOUT MENTION OF HEMORRHAGE - EOSINOPHILIC GASTRITIS, WITH HEMORRHAGE
536.2 PERSISTENT VOMITING
558.9 OTHER AND UNSPECIFIED NONINFECTIOUS GASTROENTERITIS AND COLITIS
578.0 HEMATEMESIS
643.10 HYPEREMESIS GRAVIDARUM WITH METABOLIC DISTURBANCE UNSPECIFIED AS TO EPISODE OF CARE
643.13 HYPEREMESIS GRAVIDARUM WITH METABOLIC DISTURBANCE ANTEPARTUM
643.20 LATE VOMITING OF PREGNANCY UNSPECIFIED AS TO EPISODE OF CARE
643.23 LATE VOMITING OF PREGNANCY ANTEPARTUM
643.80 OTHER VOMITING COMPLICATING PREGNANCY UNSPECIFIED AS TO EPISODE OF CARE
643.83 OTHER VOMITING COMPLICATING PREGNANCY ANTEPARTUM
780.2 SYNCOPE AND COLLAPSE
780.4 DIZZINESS AND GIDDINESS
780.97 ALTERED MENTAL STATUS
787.01 NAUSEA WITH VOMITING
787.03 VOMITING ALONE
787.91 DIARRHEA
V58.11 ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY
Group 2 Paragraph: Report an encounter for radio-contrast dye(s), when hydration is needed in conjunction with angiography and/or CT scan with contrast, with the primary diagnosis of V15.89(other specified personal history presenting hazards to health) and one of the secondary diagnoses from the list below.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 96360, 96361, J7030, J7040, J7042, J7050, J7060, J7070 and J7120:
Covered for:
Group 2 Codes:
585.3 CHRONIC KIDNEY DISEASE, STAGE III (MODERATE)
585.4 CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE)
585.5 CHRONIC KIDNEY DISEASE, STAGE V
ICD-9 Codes that DO NOT Support Medical Necessity
Paragraph: NA
General Information
Associated Information
Documentation Requirements
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
Hospital, outpatient, nursing facility or office records should clearly document the reason(s) and medical necessity for hydration therapy. The volume of hydration therapy and the doses of non-chemotherapy drugs administered should be documented in the medical record.
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
018x Hospital - Swing Beds
021x Skilled Nursing - Inpatient (Including Medicare Part A)
022x Skilled Nursing - Inpatient (Medicare Part B only)
023x Skilled Nursing - Outpatient
028x Skilled Nursing - Swing Beds
071x Clinic - Rural Health
077x Clinic - Federally Qualified Health Center (FQHC)
083x Ambulatory Surgery Center
085x Critical Access Hospital
Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Note: The contractor has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual Publication 100-04, Claims Processing Manual, for further guidance.
0250 Pharmacy - General Classification
0258 Pharmacy - IV Solutions
0260 IV Therapy - General Classification
0263 IV Therapy - IV Therapy/Drug/Supply Delivery
045X Emergency Room - General Classification
076X Specialty Services - General Classification
CPT/HCPCS Codes
Group 1 Paragraph: Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
Group 1 Codes:
96360 Hydration iv infusion init
96361 Hydrate iv infusion add-on
J7030 Normal saline solution infus
J7040 Normal saline solution infus
J7042 5% dextrose/normal saline
J7050 Normal saline solution infus
J7060 5% dextrose/water
J7070 D5w infusion
J7120 Ringers lactate infusion
ICD-9 Codes that Support Medical Necessity
Group 1 Paragraph: Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 96360, 96361, J7030, J7040, J7042, J7050, J7060, J7070 and J7120:
Covered for:
Group 1 Codes:
250.80 DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED
275.42 HYPERCALCEMIA
276.0 HYPEROSMOLALITY AND/OR HYPERNATREMIA
276.50 VOLUME DEPLETION, UNSPECIFIED
276.51 DEHYDRATION
276.52 HYPOVOLEMIA
458.9 HYPOTENSION UNSPECIFIED
535.00 - 535.01 ACUTE GASTRITIS (WITHOUT HEMORRHAGE) - ACUTE GASTRITIS WITH HEMORRHAGE
535.10 - 535.11 ATROPHIC GASTRITIS (WITHOUT HEMORRHAGE) - ATROPHIC GASTRITIS WITH HEMORRHAGE
535.20 - 535.21 GASTRIC MUCOSAL HYPERTROPHY (WITHOUT HEMORRHAGE) - GASTRIC MUCOSAL HYPERTROPHY WITH HEMORRHAGE
535.30 - 535.31 ALCOHOLIC GASTRITIS (WITHOUT HEMORRHAGE) - ALCOHOLIC GASTRITIS WITH HEMORRHAGE
535.40 - 535.41 OTHER SPECIFIED GASTRITIS (WITHOUT HEMORRHAGE) - OTHER SPECIFIED GASTRITIS WITH HEMORRHAGE
535.50 - 535.51 UNSPECIFIED GASTRITIS AND GASTRODUODENITIS (WITHOUT HEMORRHAGE) - UNSPECIFIED GASTRITIS AND GASTRODUODENITIS WITH HEMORRHAGE
535.60 - 535.61 DUODENITIS (WITHOUT HEMORRHAGE) - DUODENITIS WITH HEMORRHAGE
535.70 - 535.71 EOSINOPHILIC GASTRITIS, WITHOUT MENTION OF HEMORRHAGE - EOSINOPHILIC GASTRITIS, WITH HEMORRHAGE
536.2 PERSISTENT VOMITING
558.9 OTHER AND UNSPECIFIED NONINFECTIOUS GASTROENTERITIS AND COLITIS
578.0 HEMATEMESIS
643.10 HYPEREMESIS GRAVIDARUM WITH METABOLIC DISTURBANCE UNSPECIFIED AS TO EPISODE OF CARE
643.13 HYPEREMESIS GRAVIDARUM WITH METABOLIC DISTURBANCE ANTEPARTUM
643.20 LATE VOMITING OF PREGNANCY UNSPECIFIED AS TO EPISODE OF CARE
643.23 LATE VOMITING OF PREGNANCY ANTEPARTUM
643.80 OTHER VOMITING COMPLICATING PREGNANCY UNSPECIFIED AS TO EPISODE OF CARE
643.83 OTHER VOMITING COMPLICATING PREGNANCY ANTEPARTUM
780.2 SYNCOPE AND COLLAPSE
780.4 DIZZINESS AND GIDDINESS
780.97 ALTERED MENTAL STATUS
787.01 NAUSEA WITH VOMITING
787.03 VOMITING ALONE
787.91 DIARRHEA
V58.11 ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY
Group 2 Paragraph: Report an encounter for radio-contrast dye(s), when hydration is needed in conjunction with angiography and/or CT scan with contrast, with the primary diagnosis of V15.89(other specified personal history presenting hazards to health) and one of the secondary diagnoses from the list below.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 96360, 96361, J7030, J7040, J7042, J7050, J7060, J7070 and J7120:
Covered for:
Group 2 Codes:
585.3 CHRONIC KIDNEY DISEASE, STAGE III (MODERATE)
585.4 CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE)
585.5 CHRONIC KIDNEY DISEASE, STAGE V
ICD-9 Codes that DO NOT Support Medical Necessity
Paragraph: NA
General Information
Associated Information
Documentation Requirements
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
Hospital, outpatient, nursing facility or office records should clearly document the reason(s) and medical necessity for hydration therapy. The volume of hydration therapy and the doses of non-chemotherapy drugs administered should be documented in the medical record.
CPT Codes 96360 and 96361 are time-based codes and must be documented with start and stop times. No other service may be billed concurrently with the time represented by these codes.
https://www.cms1500claimbilling.com/2015/10/coding-information-for-hydration-therapy.html