Q&A: Documentation for hydration

February 21, 2012

QUESTION: We have a question in regards to hydration that we are trying to figure out. Does the physician specifically have to state in his or her documentation that the IV is for hydration purposes or can a coder figure it out through critical thinking and using the process of hierarchal injection/infusion coding when reading the record?

For example, X IV fluids are being used for an antibiotic and after the antibiotic, the IV fluids continue at 125/hr for hydration.

Does the physician need to document "for hydration"? Our physicians do not want to write that. Do you have any good advice on this?

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