Q:
When coding IV fluids “while not a resident” in section K of the MDS for a resident who does not have a dehydration diagnosis what documentation would support that the IVFs were administered for nutrition/hydration?
A:
The key to supporting the coding IV fluids in section K of the MDS is that the documentation supports a clinical need for the IV Fluids to impact the resident’s hydration status. Documentation to support this coding needs to include the record supporting the administration of the IV fluids during the 7 day observation period.
Additional supporting documentation may include:
- Abnormal lab results supporting a hydration need such as BUN, creatinine, sodium, elevated WBC.
- Documentation supporting inadequate oral intake to support appropriate hydration or an inability to tolerate adequate oral fluids to maintain hydration and/or prevent dehydration.
The medical record documentation including MD H+P and progress note as well as laboratory results should support the coding of IVFs for hydration.
The following are not included in Section K as IV fluids for hydration
- IV Medications
- IV fluids used to reconstitute and/or dilute medications for IV administration.
- IV fluids administered as a routine part of an operative or diagnostic procedure or recovery room stay.
- IV fluids administered solely as flushes.
- Parenteral/IV fluids administered in conjunction with chemotherapy or dialysis.
Christine Twombly, RN-BC, RAC-MT, RAC-MTA, HCRM, CHC
Clinical Consultant
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