CPT Code 96361: Hydration Infusion, Add-On, Each Additional Hour

Learn how to effectively utilize the 96361 CPT code for hydration infusion billing, ensuring accuracy and compliance. Read the guide for practical tips.

Use Code

Table of content

What is additional hour hydration infusion?CPT Code 96361 documentation requirements CPT code 96361 billing guidelines Other relevant CPT codes

Use Code

What is additional hour hydration infusion?

CPT code 96361 is an add-on code used to report each additional hour of intravenous hydration infusion beyond the first hour (reported with 96360). It applies only when fluids such as normal saline, D5W, or pre-packaged fluids are provided without drug administration, solely for hydration therapy due to conditions like dehydration, fluid loss, abnormal fluid losses, inability to ingest fluids, or electrolyte deficiency.

It is intended to be reported only after the initial hydration service. It must be supported by clear documentation in the medical record that meets medical necessity criteria, such as abnormal vital signs, elevated BUN (Blood Urea Nitrogen), creatinine, or glucose, or abnormal laboratory studies.

CPT 96361 is not appropriate for routine administration of IV fluids. It requires physician documentation and proper clinical indicators.

CPT Code 96361 documentation requirements

To ensure accurate billing and appropriate reimbursement for infusion therapy, follow these billing rules for CPT code 96361:

Report only with CPT code 96360 (the initial hydration service).
Time must exceed 31 minutes into the additional hour to report CPT 96361.
Hydration must involve IV hydration via same IV access or separate IV line if reported with therapeutic infusion.
Do not report CPT 96361 for infusion and injection services involving drugs or chemotherapy infusions—use therapeutic infusion codes, such as 96365, instead.
Hydration given only as a pre- or post-infusion flush is not billable.
When multiple infusions occur, each must be clearly documented with infusion start/stop times, IV access location, and purpose (e.g., hydration infusion vs. drug administration).
Applies to both facility settings and Medicaid services, if documentation supports medical necessity.

To ensure compliance and avoid denial, the hydration codes must reflect infusion services that are medically indicated and performed by a qualified healthcare professional.

CPT code 96361 billing guidelines

Your medical record must clearly support the use of CPT 96361. It should include:

Reason for IV hydration (e.g., fluid loss, dehydration, or elevated lab values like creatinine, glucose, or lactic acid)
Documented start and stop times
Type and amount of IV fluids (e.g., normal saline, D5W)
Method of intravenous infusion (e.g., gravity drip or infusion pump)
Confirmation that the service was ordered and monitored by a provider

This helps ensure proper reimbursement and satisfies payer documentation requirements.

Other relevant CPT codes

96360 – Initial hydration infusion, first hour
96365 – Therapeutic infusion, initial
96366 – Additional hour, therapeutic infusion
96375 – Sequential IV push injection, additional medication

Frequently asked questions

What is the proper usage of CPT code 96361?

CPT 96361 is used to report IV hydration services when intravenous infusion hydration continues beyond the initial hour. It must always follow an initial service code, such as 96360, which serves as the code for the primary procedure. Ensure the documentation supports this additional time to report infusion accurately.

Can CPT 96361 be used during chemotherapy infusion?

No. Chemotherapy infusion has its own distinct set of infusion codes and requires separate billing. CPT 96361 is specific to hydration infusion and cannot be substituted for therapeutic or chemotherapeutic infusions, even in patients with elevated BUN, creatinine, or glucose levels.

Can I report 96361 if multiple infusions are given through the same IV line?

You may report IV infusion services, such as 96361, for multiple infusions, but only if each infusion meets the required criteria. When hydration is provided through the same IV line as an IV push or a concurrent infusion, ensure separate indications and documentation are in place to bill each correctly. Only one initial hydration service can be reported, unless a new, medically necessary injection is administered.