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Basics about CPT code 96365, 96372, 96374 and 96360

Coding of diagnostic and therapeutic infusion, hydration are based on the stated hierarchy. As per the hierarchy, infusions should be coded primary to pushes, which is primary to injections. This hierarchy is to be followed in facility coding. However, for both physician and facility coding only one initial service code should be reported unless the documentation in the report support the two separate IV sites infusion or injection.

For example, CPT code 96365 is used for coding the primary or initial code as per hierarchy and suppose if there are two or more IV site for infusion, then you can go ahead and used the same code with 59 or X-{EUPS}modifier (96365, 96359-XU). Another one, CPT code 96372 is used to code for a medical procedure under the range of therapeutic, diagnostic, and prophylactic injections and infusions.

Definition related to CPT code 96372, 96365, 96374 and 96360

Infusion: A controlled method of administering a substance (drugs, fluids, nutrients, etc) continuously over an extended period of time.
Injection: Insertion of a drug, substance, or solution into the body part (ex: subcutaneous tissue, muscle, vascular tree, or an organ).

IV Infusion (96365-96368)>IV pushes (96374-96376)> Injection (96372-96373) ( >Hydration (96360, +96361)

Description of CPT code 96372, 96365, 96366 & 96367

The 96372 CPT code is is a procedural code defined as therapeutic, prophylactic, and diagnostic substance by subcutaneous or intramuscular injections and infusions. While this code is not often used in the mental and behavioral health setting, there are certain specialties that do use it. For example, outpatient behavioral health and substance use disorder facilities may use this code in their treatment process. Most commonly, this is used more specifically for the extended-release naltrexone injection during substance abuse treatment.

96372 – Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular

96365 – Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour
+96366 – each additional hour (List separately in addition to code for primary procedure)
+96367 – additional sequential infusion of a new drug/substance, up to 1 hour (List separately in addition to code for primary procedure)

The initial code should be selected based on the hierarchy. The hierarchy does not apply to physician coding. This hierarchy is only to be followed in facility coding.

For multiple injection or infusions, use the primary code for the initial service based on hierarchy for facility coding. And use add-on codes for the reporting the additional services by calculating the time.

CPT code 96372 is to be billed for each injection performed on a patient. Modifier 59 should be used when the injection is a separate service from other treatments. A therapeutic, prophylactic, or diagnostic substance (a fluid, a drug, etc.) is injected via intramuscular or subcutaneous route into the patient’s body. The procedure is performed by the physician himself or by his assistant or nurse under direct supervision of the physician. Injection of a vaccine or toxoid is not included in this code.

Subsequent codes related to this code include:

96373 – therapeutic, prophylactic, and diagnostic substance by intra-arterial injections and infusions

96374 – intravenous push, single or initial substance/drug

+96375 – each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure)

+96376 – each additional sequential intravenous push of the same substance/drug provided in a facility (List separately in addition to code for primary procedure)

96360 – Intravenous infusion, hydration; initial, 31 minutes to 1 hour

+96361 – each additional hour (List separately in addition to code for primary procedure)

Droperidol uses, brand name injection and its dose

Reasons for CPT code 96372 Denials

Procedure code 96372 is reported by the physician in a facility setting.
CPT code 96372 is submitted together with an E/M service and with CMS Place of Service (codes) 19, 21, 22, 23, 24, 26, 51, 52, and 61 for the same patient by the same individual physician or other qualified healthcare professional on the same date of service. Only the E/M service will be reimbursed regardless of whether a modifier is reported with injection(s).
Code 96372 is performed by another healthcare provider, other than the physician or other qualified health professionals, without direct supervision for any or all purposes of patient assessment, provision of consent, safety oversight, and intra-service supervision of staff in a non-facility setting. To report this kind of circumstance, CPT code 99211 would be appropriate.
The CPT code 96372 already includes a general assessment of the patient.
If the need for the injection was already determined at the previous visit (billed as an E/M code), you cannot bill again for the same service. However, you can bill for the injection and an E/M code at the same visit if there was an additional E/M service provided in addition to the injection. That E/M service would have to be appropriately documented.
Inappropriate or missing modifier.
CPT code 96372 is not properly documented indicating that a procedure or service was distinct or independent from other services performed on the same day.
CPT code 96372 is used for certain types of vaccinations. Most vaccinations are typically coded with 90471 or 90472. Medicare uses G0008 as the administration code for flu vaccinations.
Procedure code 96372 is billed for injections related to the provision of chemotherapy services. The proper CPT code to use is 96401-96402.

Use of Modifier 59 with CPT code 96372

As per the CPT manual, Modifier 59 is used to describe a certain service or procedure performed by a healthcare provider as distinct or separate from other procedures/services performed on the same patient on the same date. Essentially, modifier 59 documents procedures/services that generally aren’t documented in conjunction but are appropriate to do so only for some special cases.

However, this modifier should not be used on an E/M code and should only be used when no other modifier seems appropriate. This is why it is called the ‘last resort modifier’. Only if no other modifier is deemed fit for the situation is modifier 59 used.

As we’ve already established, if a patient is given more than one subcutaneous or intramuscular injection, then each injection should be invoiced with a separate CPT code. Modifier 59 will then be used along with the second and every other subsequent injection code billed on the claim form. This is to indicate that the second and every other injection that follows is a separate service from the first injection.

However, if the volume of a single intramuscular or subcutaneous dose needs to be split into two or more syringes, you can only bill for a single unit of code 96372. For example, if you administer two different drugs to a patient, but have to use three separate injections to administer them, you would only bill for CPT code 96372 twice along with their drug supply codes and a modifier 59 code on the second injection code like this:

CPT 96372 (Therapeutic, diagnostic, and/or prophylactic injection, specify drug or substance; intramuscular or subcutaneous)

CPT 96372-59 (Therapeutic, diagnostic, and/or prophylactic injection, specify drug or substance; intramuscular or subcutaneous – Distinct Procedural Service)

Modifier 25 must also be attached with an Evaluation and Management code if an injection is given to the patient, but the Evaluation and Management service is not linked with the service of administering an injection to the patient. For example, a patient presents to your clinic with shoulder pain and was diagnosed with a respiratory infection during their exam. The physician injected Vancomycin drug into the patient for the respiratory infection.

In this particular example, the medical coder will append modifier 25 with an E/M code for the shoulder pain and will append modifier 59 to CPT code 96372 for the administration of the Vancomycin.

Basic Infusion Guidelines per CMS

• Only one initial service may be coded per encounter.
• A bolus of prepackaged fluids or other specific medications should be coded as therapeutic.
• Start and stop times determine how to calculate the hour(s).
• The additional hour can be included only when the infusion has lasted more than 30 minutes into the second hour.
• The fluid used to administer drug(s) is incidental hydration and is not separately pay

Subsequent infusion is a IV push of a new substance or drug following the initial or primary service.

+96367 – additional sequential infusion of a new drug/substance, up to 1 hour (List separately in addition to code for primary procedure)

Concurrent infusion is a new drug or substance infused at the same time as another substance or drug. This infusion is not time based and should be reported only once per day. Hydration is not allowed to reported concurrently with any other service.

+96368 – Concurrent infusion (report only one per encounter)

Calculate time to find Correct CPT code

The start and stop time should be clearly documented to t code these services. Most of the time the start is documented but the stop time is not present in the medical report. For single infusion less than 15 minutes can be assumed as the IV push

Do not report CPT code 96365, 96374, 96372 and 96360 together unless there are two or more IV sites for infusion or injection. We can code only one primary code based on the hierarchy in facility coding.

All add-on codes (+) should be used secondary codes along with other services. For example, IV push code +96375 can be coded as secondary code with initial IV infusion CPT code 96365.

Intravenous infusions

IV infusions are reported with CPT code 96365-96368 and are divided based on the time and type of infusion. The initial infusion is reported with CPT code 96365 (upto 1 hour) once per encounter, unless the protocol requires two different venous accesss sites; each additional hour of the same drug/substance (upto 8 hours) is reported with CPT code 96366. In order to report CPT code 96366, there must be infusion intervals of greater than 30 minutes (upto 1 hour), beyond the initial 1-hour increment of infusion.

Different drug/substance

Sometimes one infusion is provided and followed by another infusion of a different drug/substance (sequential infusions); in this case, the initial infusion is reported first with CPT cde 96365, and the additional sequential infusion is reported with add-on CPT code 96367 for each separate infusate mix.

Sequential, initial concurrent infusions

When a sequential infusion runs for more than 1 hour, the cpt guidelines following code 96366 instruct the coder to report CPT code 96366 for additional sequential hour(s). There are times more than one infusion of a different drug or substance is provided at the same time, in which case the initial or sequential infusion is listed first, and then the additional concurrent infusion is listed (96368). Code 96368 can be reported only once per encounter. If multiple drugs are mixed together in the same bag, only one administration code can be reported, but all drugs should be billed separately.

Substance infusions

Subcutaneous infusion for therapy is reported with codes 96369-96371. The initial subcutaneous infusion CPT code 96369 reports up to 1 hour of infusion, and included the pump set-up and establishment of the site. Code 96370 is an add-on code that reports each additional hour, and 96371 is also an add-on code that reports an additional pump set-up with establishment of a new subcutaneous site.

Therapeutic, prophylactic and diagnostic injections

Therapeutic, prophylactic and diagnostic injections are divided based on the administration method. Subcutaneous and intramuscular injections are reported with 96372, along with a code to report the substance injected. This code cannot be reported when injections are given without direct physician or other qualified professional supervision and does not include injections for allergen immunotherapy.

96372 -Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular

Intraarterial Injection

Intraarterial injections are reported with code 96373. IV push is reported with 96374 for a single or intial drug or substance. Intraarterial or IV push is defined as an infusion lasting 15 minutes or less, or an injection in which the individual who administers the drug or substance is continually present to administer the injection and observe the patient. Additional sequential IV push is reported with add-on codes 96375 for a new drug or substance or 96376 for the same drug or substance when provide in a facility. Once again, all drugs are to be separately using HCPCS national level II codes or CPT code 99070.

Hydration

Typically an administration of prepackaged fluids and/or electrolytes without drugs. Examples include normal saline (NS), sodium chloride (NaCl), dextrose 5 percent in water (D5W), dextrose in ½ normal saline (D5 ½ saline), dextrose in ½ normal saline plus potassium (D5 ½ NS+K). CPT code 96360 & 96361 are used for coding hydration.

Reimbursement Guidelines

Facility, Emergency Room, and Ambulatory Surgical Center Services:
Per CPT and the CMS National Correct Coding Initiative (NCCI) Policy Manual, CPT codes 96360-96379 are not intended to be reported by the physician in the facility setting. Thus, when an E/M service and a therapeutic and diagnostic Injection service are submitted with CMS Place of Service (POS) codes 19, 21, 22, 23, 24, 26, 51, 52, and 61 for the same patient by the Same Individual Physician or Other Health Care Professional on the same date of service, only the E/M service will be reimbursed and the therapeutic and diagnostic Injection(s) is not separately reimbursed, regardless of whether a modifier is reported with the Injection(s).

Non-Facility Injection Services:

E/M services provided in a non-facility setting are considered an inherent component for providing an Injection service. CPT indicates these services typically require direct supervision for any or all purposes of patient assessment, provision of consent, safety oversight, and intra-service supervision of staff. When a diagnostic and therapeutic Injection procedure is performed in a POS other than 19, 21, 22, 23, 24, 26, 51, 52, and 61 and an E/M service is provided on the same date of service, by the Same Individual Physician or Other Health Care Professional, only the appropriate therapeutic and diagnostic Injection(s) will be reimbursed and the E/M service is not separately reimbursed.

If a significant, separately identifiable E/M service is performed unrelated to the physician work (Injection preparation and disposal, patient assessment, provision of consent, safety oversight, supervision of staff, etc.) required for the Injection service, Modifier 25 may be reported for the EM service in addition to 96372-96379. If the E/M service does not meet the requirement for a significant separately identifiable service, then Modifier 25 would not be reported and a separate E/M service would not be reimbursed.

CPT code 96372, 96365, 96374 and 96360: Coding Guidelines