Medical billing and coding are crucial to the healthcare system, enabling accurate billing and data collection. Proper knowledge of terminology is essential for assigning the correct codes to ensure accurate patient records. Understanding the reason for the denial or rejection of a particular CPT injection code and resubmitting the claim with the appropriate qualifier is necessary. The 96372 CPT code refers to a therapeutic, prophylactic, or diagnostic injection in a physician’s office or outpatient setting. Correctly using this code is essential for ensuring proper reimbursement for healthcare providers. Using modifiers correctly and ensuring their compatibility with the CPT code is necessary to prevent billing denials, including denial codes such as CO4. Maximizing reimbursement for healthcare providers through accurate coding and billing is vital for the growth and success of the healthcare industry.
Understanding The CPT Code 96372
CPT code 96372 identifies a medical procedure used for therapeutic, diagnostic, and prophylactic purposes related to injections and infusions. Medical professionals use this code to bill for medication administration through an intramuscular or subcutaneous injection. This type of injection involves a single-shot administration, in contrast to a slow intravenous administration that requires more time. The American Medical Association maintains and updates the CPT code set, including the 96372 code.
Here are some related CPT codes to 96372 and their brief descriptions:
|96373||Intra-arterial injection for therapeutic, diagnostic, or prophylactic purposes|
|96374||Intravenous push injection of a single or initial drug or substance for therapeutic, diagnostic, or prophylactic purposes|
|96375||Additional or subsequent intravenous injection of a new drug or substance for therapeutic, diagnostic, or prophylactic purposes|
|96376||Additional or subsequent intravenous injection of the same drug or substance for therapeutic, diagnostic, or prophylactic purposes|
|96377||Injection via an on-body injector for therapeutic, diagnostic, or prophylactic purposes, such as the insertion of a cannula|
These codes are used to bill for various therapeutic, diagnostic, or prophylactic injections in different ways and with different frequencies.
Reasons For CPT code 96372 Denials
Here are some reasons why CPT code 96372 may be denied, as per AMA CPT and CMS guidelines:
- It may get denied if a physician reports CPT code 96372 in a facility setting.
- Submitting CPT code 96372 with an E/M service and specific 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 qualified healthcare professional on the same date of service will result in only the E/M service being reimbursed, regardless of any modifiers reported with the injection (s).
- Performing procedural code 96372 without direct supervision for patient assessment, provision of consent, safety oversight, and intra-service supervision of staff in a non-facility setting by another healthcare provider who is not a physician or other qualified healthcare professional may result in non-reimbursement under this code.
- Using procedure code 96372 to bill for a provided service during a previous visit or billed as an E/M code during the same visit will result in denial.
- To bill an additional E/M service provided with the injection during the same visit, the healthcare provider must ensure appropriate documentation is in place.
- The incorrect or missing modifier can lead to the denial of CPT code 96372.
- CPT code 96372 should be adequately documented to indicate that it is a particular or independent service from other services provided on the same day.
- Using procedure code 96372 for vaccinations is inappropriate; instead, codes like 90471, 90472, or G0008 (for Medicare) should be used.
- The appropriate CPT codes to use for injections related to chemotherapy services are 96401-96402.
CPT Code 96372 Reimbursement Criteria
CPT code 96372 can be reimbursed alone or with other approved procedures by the National Correct Coding Initiative process. However, no additional reimbursement will be granted if it is billed along with an E/M service performed by the same provider on the same day. Physicians must document the drug name and dose in the correct section of the billing form when administering medication.
Medical coders struggle with CPT code 96372, leading to incorrect billing and non-payment for injection administration by healthcare providers.
- The reporting of CPT codes 96372-96379 is not intended for physicians in a facility setting. When submitting an E/M service and an injection service for the same patient on the same service date, only the E/M service is reimbursed, regardless of whether a modifier is used for the injection (s). The therapeutic or diagnostic injection (s) will not receive separate reimbursement.
- In a non-facility setting, an E/M service and injection may be necessary components. If an E/M service is separately identifiable, Modifier 25 can report it with 96372-96379, and Modifier 25 reports the E/M service along with 96372-96379. Appropriately documenting the E/M service is necessary to support its separate identity.
- When submitting a diagnostic or therapeutic Injection code, E/M service code 99211 will not be reimbursed, regardless of whether Modifier 25 is used. The code is considered a very low service level and does not meet the definition of ‘significant’ according to CPT, so reporting it in addition to the Injection procedure code should not be done.
- Modifier 25 is not necessary to indicate a significant, separately identifiable service when reporting Preventive Medicine codes (99381-99412, 99429) and a diagnostic or therapeutic injection code. It encompasses routine services like ordering immunizations or diagnostic procedures, which should be reported along with the Preventive Medicine E/M code. Thus, diagnostic and therapeutic Injections can be billed together with a Preventive Medicine code without the need for Modifier 25.
- If an E/M service and an Injection or Infusion service are submitted on the same date of service for a patient, it is assumed that the E/M service is included in the procedure. To avoid this presumption, the physician must indicate that the E/M service is separately identifiable.
- If the same physician performs an Injection procedure and an E/M service on the same day, you can reimburse each service separately if they are provided in different places of service. However, if the injection was given in one of the specified POS codes (19, 21, 22, 23, 24, 26, 51, 52, and 61), the services will not be separately reimbursed. Suppose a patient receives an injection at a physician’s office (POS 11) and is subsequently admitted to a hospital (POS 21) on the same day. In that case, the injection and the later E/M services performed at the hospital will be reimbursed separately.
- When submitting an E/M service and a procedure on the same day for a patient, the E/M service is presumed part of the procedure unless specified otherwise. Nevertheless, the Injection procedure does not include a Preventive Medicine E/M service. Therefore, the injection can be reported separately, and the Preventive Medicine E/M code does not require a modifier to indicate that it is distinct or separate from the Injection procedure.
Use of Modifier 59 with CPT 96372
Modifier 59 reports acceptable, non-simultaneous procedures, excluding E/M services, under specific circumstances. It should only be used if no other explanatory modifiers are available and it explains the situation. When administering multiple intramuscular or subcutaneous injections to a patient, each injection should be reported separately using CPT code 96372. If the patient receives a second or subsequent injection, modifier 59 should be appended to indicate that it is a distinct procedural service. Remember that direct physician supervision is necessary for professional reporting of code 96372. For modifier 59, medical records should document that each injection was a separate service to support its use.
If a patient has knee pain and osteoarthritis, a doctor may give a Toradol injection to relieve the pain. To report an office visit diagnosis, use a 25 modifier. Additionally, report substance and administration separately using CPT codes 96372 and 59. The resulting claim would have three line items, each reflecting a distinct service. To bill for a patient experiencing knee pain (ICD-10 25.569 or ICD-9 719.46) and diagnosed with osteoarthritis (ICD-10 M17.9 or ICD-9 715.96), healthcare providers must use the following: codes.
- CPT code 99213 with a 25 modifier for the office visit related to the knee pain
- CPT code J1885 for the administration of medication for osteoarthritis
- CPT code 96372 with a 59 modifier to indicate separate procedural services for each injection of medication administered for osteoarthritis
A claim should include three distinct codes for separate procedures to bill for knee pain, osteoarthritis, and medication administration.
How To Appeal Denied Claims
Healthcare providers may have their service claims denied by insurance companies, leaving the possibility of non-payment. A denied claim means that the insurance company has reviewed it and decided not to pay for it. It can be frustrating for healthcare providers to count on payment to cover their costs.
The first step in appealing a denied claim is to determine the reason for the denial. Some common reasons for denied claims include the following:
- Inaccurate or incomplete information on the claim form
- Lack of medical necessity for the provided services
- Failure to obtain pre-authorization for the service
- The patient’s insurance plan does not cover the provided service
- Timely filing limits exceeded
To avoid denied claims, healthcare providers should submit complete and accurate information on the claim form. They should also verify that the patient’s insurance plan covers the service. It can obtain any necessary pre-authorizations before providing the service.
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