Medicare Advantage Preferred Provider Organization (MA PPO)

Applicable to enrollees from other Blue Cross Blue Shield Medicare Advantage Plans who obtain health care services within the 5-county Philadelphia service area.

Title:

Intravenous (IV) Administration of Fluids as a Treatment of a Medical Condition or for the Preparation of Pharmaceuticals, Biologics, and other Substances

Policy #:

MA00.022

Policy

INTRAVENOUS (IV) ADMINISTRATION OF FLUIDS FOR THE TREATMENT OF A MEDICAL CONDITION

Administration of IV fluids for the treatment of a medical condition (e.g., dehydration, prevention of dehydration, or toxicity) is covered and eligible for reimbursement consideration by the Company. However, if the IV fluids for the treatment of a medical condition are infused during the same session for which IV fluids are also used to prepare the administration of pharmaceuticals, biologics, and other substances, only the fluids administered as a treatment for a medical condition are eligible for reimbursement consideration. In such cases, all of the following requirements must be met:

The IV fluids that are being used to treat a medical condition must be separately and sequentially (i.e., not concurrently) infused with the pharmaceuticals, biologics, and other substances.
This sequential administration of IV fluids for the treatment of a medical condition must be, in and of itself, medically necessary due to the fact that a concurrent IV fluid and medication administration is medically contraindicated.
This sequential IV fluid administration must not be performed as a means to obtain separate reimbursement.

IV FLUIDS USED FOR THE PREPARATION OF PHARMACEUTICALS, BIOLOGICS, AND OTHER SUBSTANCES

The Company covers the use of intravenous (IV) fluids for the preparation (dilution, reconstitution) of pharmaceuticals, biologics, and other substances for IV administration. However, such use is considered to be integral to the administration of the pharmaceutical, biologic, or other substance and is, therefore, not eligible for reimbursement. Participating providers may not bill members for this service.

ADMINISTRATION OF FLUIDS FOR MAINTENANCE OF VASCULAR ACCESS
The administration of an IV flush or other services that are necessary for maintenance of vascular access are not eligible for separate reimbursement from other procedures requiring vascular access.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, records from the health care professional's office, hospital, nursing home, home health agencies, and therapies, as well as test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

This policy is consistent with Medicare's National Correct Coding Initiative (NCCI) Manual and the American Medical Association's (AMA) Current Procedural Terminology (CPT®) Guidelines for Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration.

This policy is consistent with Medicare's coverage determination. The Company's payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, intravenous (IV) administration of fluids for the treatment of a medical condition is covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

Description

Intravenous (IV) fluids may be administered for the treatment of a medical condition (e.g., dehydration, prevention of dehydration or toxicity) or used to prepare (e.g., dilute, reconstitute) pharmaceuticals, biologics, and other substances for IV administration. The medical conditions for which IV fluids may be administered as a treatment include, but are not limited to, fluid and electrolyte imbalances and other volume disturbances (e.g., dehydration). An example of a substance that may require dilution is IV administration of potassium chloride (KCl).

References

Centers for Medicare & Medicaid Services (CMS). National Correct Coding Initiative (NCCI) Policy Manual for Part B Medicare Carriers. Chapter I, Version 15.3: General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services. [CMS Web site]. 10/01/09. Available at: http://www.cms.hhs.gov/NationalCorrectCodInitEd/Downloads/NCCI_Policy_Manual.zip. Accessed September 10, 2019.

Papadakis Maxine A., McPhee Stephen J., Rabow, Michael W., eds. Current Medical Diagnosis and Treatment 2019. 58th edition. New York, NY: McGraw-Hill; 2018.

Coding

CPT Procedure Code Number(s)

N/A

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

N/A

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Version Effective Date:

1/1/2015

Version Issued Date: