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Official Description

Intravenous infusion, hydration; initial, 31 minutes to 1 hour

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

An intravenous infusion for hydration involves the administration of fluids directly into a patient's bloodstream through a vein, typically located in the arm. This procedure is crucial for restoring fluid balance in patients who may be experiencing dehydration or who are unable to consume adequate fluids orally. The infusion process begins with the placement of an intravenous (IV) line, which allows for the controlled delivery of fluids and electrolytes. The physician overseeing the procedure ensures that the patient is monitored closely throughout the infusion, providing direct supervision and being readily available to address any complications that may arise. Additionally, the physician conducts periodic assessments to evaluate the patient's response to the treatment, ensuring that the hydration is effective and adjusting the treatment as necessary. For billing purposes, the CPT® code 96360 is utilized for the initial infusion duration of 31 minutes to 1 hour, while the code 96361 is designated for each subsequent hour of hydration administered.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The intravenous infusion for hydration is indicated in various clinical scenarios where patients require fluid replacement or supplementation. The following conditions may warrant this procedure:

  • Dehydration Patients experiencing dehydration due to excessive fluid loss, such as from vomiting, diarrhea, or excessive sweating, may require intravenous hydration to restore fluid balance.
  • Inability to Maintain Oral Intake Individuals who are unable to consume adequate fluids orally due to medical conditions, surgical recovery, or other factors may benefit from intravenous fluid administration.
  • Electrolyte Imbalance Patients with imbalances in electrolytes, which can occur due to various medical conditions, may require hydration to help restore normal electrolyte levels.

2. Procedure

The procedure for intravenous infusion for hydration involves several key steps to ensure safe and effective administration of fluids. The following outlines the procedural steps:

  • Step 1: Patient Preparation The patient is prepared for the procedure by explaining the process and obtaining informed consent. The healthcare provider assesses the patient's medical history and current condition to determine the appropriate type and volume of fluid to be administered.
  • Step 2: IV Line Placement A suitable vein, typically in the arm, is selected for the insertion of the intravenous catheter. The area is cleaned with an antiseptic solution to minimize the risk of infection. The catheter is then inserted into the vein, and proper placement is confirmed.
  • Step 3: Fluid Administration Once the IV line is established, the prescribed fluid is connected to the IV catheter. The infusion is initiated, and the flow rate is adjusted according to the physician's orders. The healthcare provider monitors the infusion closely to ensure that the patient is tolerating the fluid well.
  • Step 4: Monitoring and Assessment Throughout the infusion, the physician or healthcare provider conducts periodic assessments of the patient's vital signs and overall response to the treatment. Any adverse reactions or complications are addressed immediately.
  • Step 5: Documentation After the infusion is completed, the healthcare provider documents the procedure, including the type and volume of fluid administered, the duration of the infusion, and the patient's response to treatment.

3. Post-Procedure

After the intravenous infusion for hydration is completed, the patient is monitored for any immediate reactions or complications. The IV line is typically removed, and the site is assessed for any signs of irritation or infection. Patients may be advised to continue oral hydration as appropriate and to report any symptoms of dehydration or electrolyte imbalance. Follow-up assessments may be scheduled to evaluate the patient's ongoing hydration status and overall health.

Short Descr HYDRATION IV INFUSION INIT
Medium Descr IV INFUSION HYDRATION INITIAL 31 MIN-1 HOUR
Long Descr Intravenous infusion, hydration; initial, 31 minutes to 1 hour
Status Code Active Code
Global Days XXX - Global Concept Does Not Apply
PC/TC Indicator (26, TC) 5 - Incident To Code
Multiple Procedures (51) 0 - No payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 0 - Payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Procedure or Service, Not Discounted when Multiple
Berenson-Eggers TOS (BETOS) P6C - Minor procedures - other (Medicare fee schedule)
MUE 1
CCS Clinical Classification 231 - Other therapeutic procedures

This is a primary code that can be used with these additional add-on codes.

96361 Addon Code MPFS Status: Active Code APC S CPT Assistant Article Intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure)
96366 Addon Code MPFS Status: Active Code APC S CPT Assistant Article 1Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure)
96367 Addon Code MPFS Status: Active Code APC S CPT Assistant Article 1Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour (List separately in addition to code for primary procedure)
96368 Addon Code MPFS Status: Active Code APC N CPT Assistant Article 1Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure)
96375 Addon Code MPFS Status: Active Code APC S CPT Assistant Article 1Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure)
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study
GA Waiver of liability statement issued as required by payer policy, individual case
XE Separate encounter, a service that is distinct because it occurred during a separate encounter
Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
GZ Item or service expected to be denied as not reasonable and necessary
CR Catastrophe/disaster related
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
PD Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days
GC This service has been performed in part by a resident under the direction of a teaching physician
GW Service not related to the hospice patient's terminal condition
58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
76 Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
GV Attending physician not employed or paid under arrangement by the patient's hospice provider
X1 Continuous/broad services: for reporting services by clinicians, who provide the principal care for a patient, with no planned endpoint of the relationship; services in this category represent comprehensive care, dealing with the entire scope of patient problems, either directly or in a care coordination role; reporting clinician service examples include, but are not limited to: primary care, and clinicians providing comprehensive care to patients in addition to specialty care
JZ Zero drug amount discarded/not administered to any patient
Q0 Investigational clinical service provided in a clinical research study that is in an approved clinical research study
LT Left side (used to identify procedures performed on the left side of the body)
22 Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service.
25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service: it may be necessary to indicate that on the day a procedure or service identified by a cpt code was performed, the patient's condition required a significant, separately identifiable e/m service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. a significant, separately identifiable e/m service is defined or substantiated by documentation that satisfies the relevant criteria for the respective e/m service to be reported (see evaluation and management services guidelines for instructions on determining level of e/m service). the e/m service may be prompted by the symptom or condition for which the procedure and/or service was provided. as such, different diagnoses are not required for reporting of the e/m services on the same date. this circumstance may be reported by adding modifier 25 to the appropriate level of e/m service. note: this modifier is not used to report an e/m service that resulted in a decision to perform surgery. see modifier 57 for significant, separately identifiable non-e/m services, see modifier 59.
51 Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
52 Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
53 Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
56 Preoperative management only: when 1 physician or other qualified health care professional performed the preoperative care and evaluation and another performed the surgical procedure, the preoperative component may be identified by adding modifier 56 to the usual procedure number.
57 Decision for surgery: an evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of e/m service.
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
95 Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system: synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. modifier 95 may only be appended to the services listed in appendix p. appendix p is the list of cpt codes for services that are typically performed face-to-face, but may be rendered via a real-time (synchronous) interactive audio and video telecommunications system.
AG Primary physician
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
CC Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
GY Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit
KX Requirements specified in the medical policy have been met
PO Excepted service provided at an off-campus, outpatient, provider-based department of a hospital
Q5 Service furnished under a reciprocal billing arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
RT Right side (used to identify procedures performed on the right side of the body)
SA Nurse practitioner rendering service in collaboration with a physician
TA Left foot, great toe
X2 Continuous/focused services: for reporting services by clinicians whose expertise is needed for the ongoing management of a chronic disease or a condition that needs to be managed and followed with no planned endpoint to the relationship; reporting clinician service examples include but are not limited to: a rheumatologist taking care of the patient's rheumatoid arthritis longitudinally but not providing general primary care services
XP Separate practitioner, a service that is distinct because it was performed by a different practitioner
Date
Action
Notes
2011-01-01 Changed Short description changed.
2009-01-01 Added -
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