I bill in the urgent care setting and want information of billing of cpt codes of 96360 and 96361.
I know that if patient has Iv push or iv infusion of med then 96365 or 96374 would be first to come and 96361 to code is dehydration

Do i need the chart note to specify that the patient is "dehydrated or given normal saline for dehydration" in order to bill correctly?

If patient comes in with symptoms of nauseas and vomiting does that assume he is dehydrated?

please help