Question 1

How can you stay updated with medical coding guidelines and regulations?

Accepted Answer

Stay current with medical coding guidelines by joining professional organizations like AAPC, attending webinars, engaging in online forums, and reviewing updates from CMS. These steps ensure you're always informed and compliant.

Question 2

What documentation is required to bill for IV Hydration (96360)

Accepted Answer

Because hydration is a time-based service, and without a documented stop time, there is no way to prove the duration.
Even if:
 • The fluid is documented
 • The start time is present
 • The order is valid
 It is still not billable
This is one of the most common missed revenue opportunities in coding.
See how to catch this inside the

Infusion Coding Guide(/infusion-and-injections-coding-wearemedicalcoders)

Question 3

Can an IV infusion be coded without a stop time?

Accepted Answer

Not as an infusion.
If no stop time is documented, the service may only qualify as an IV push, depending on the documentation.
This is where coders lose accuracy by:
 • Assuming infusion
 • Not verifying duration
 Learn how to validate this using the

Epic MAR Guide(/the-mar)

Question 4

What is the biggest documentation mistake coders miss?

Accepted Answer

Not reading the full clinical picture.
Coders often:
 • Pull from one section (like the MAR)
 • Ignore physician intent
 • Miss conflicting documentation
Coding isn’t about finding a data point, it’s about confirming the entire story supports the code.
This is explained deeper in Confident Coding Decisions(/post/how-to-make-confident-coding-decisions-inside-the-chart)

Question 5

How to read epic mar for coding?

Accepted Answer

To read the Epic MAR for coding, start by reviewing the medication entry, then identify start and stop times, determine whether the service is an IV push or infusion, and verify the route and details of administration. Always cross-check the MAR with provider documentation to confirm accuracy and support correct charge capture.
 
Learn more in the i(/infusion-and-injections-coding-wearemedicalcoders)nfusion coding guide(/infusion-and-injections-coding-wearemedicalcoders)
See a full breakdown in the Epic MAR for coders (/my-epic-option)page

Question 6

How do you determine IV push vs infusion in coding?

Accepted Answer

The difference is based on time and administration method. IV pushes are typically short and not time-based, while infusions require documented duration. Always verify using the MAR and supporting documentation.
👉 See examples in the Epic MAR for coders(/the-mar) (/the-mar)page

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Documentation Requirements to code infusion and injection

Latest Updates

Understanding IV Hydration CPT Codes: A Comprehensive Guide

Understanding Epic's Medication Administration Record (MAR) for Billing and Coding

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Essential Documentation Requirements for Infusion and Injections

Epic EMR Charge Capture: Hospital Outpatient Workflow Guide

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