Medical Coding Infusions 96368 & 96366

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The next one is an ER case. The patient is febrile and dehydrated with a suspicious chest x-ray with possible pneumonia. They received an IV hydration infusion for over six hours of Lactated Ringers – that’s a pretty common hydration thing – as well as infusion of Vancomycin over 1 hour. So, how are we going to code this out? What is the medical necessity? It’s for hydration. So, 96361 is what we’re going to code and the infusion of antibiotic is going to be reported as the primary infusion with one unit 96365, so six units of the hydration and then the antibiotic 96365. That makes sense.
Again, to really answer both parts of the question, we need more information on this ER and point of service and stuff like that, so without knowing why was the patient getting the hydration? Why were they set up for observation in the ER? What was the reason for the start and stop? We can’t really answer that question properly, but that’s the resources and the codes to go by, to go forward. Hopefully, you can do your own research off of that.