Welcome to another blog in our series, where we dissect the most searched CPT codes to clear our readers’ coding confusion. In today’s blog, we will discuss CPT code 96372, which is one of the most frequently reported CPT codes at pain management practices, OB/GYN clinics, and outpatient primary care centers.
So, let’s dive deep and explore CPT code 96372’s description, applications, denial reasons, and billing best practices.
96372 CPT Code – Description
The Current Procedural Terminology (CPT) code 96372 reports injecting a therapeutic, diagnostic, or prophylactic drug or biological into the patient’s body through the intramuscular (via the muscle) or subcutaneous (via the skin) route. The drug can be administered directly by the physician or his trained staff (a nurse or an assistant) under his supervision.
Note that CPT code 96372 is not valid for vaccines, toxoids, or chemotherapy drugs because the American Medical Association (AMA) has separate CPT codes for injecting those substances into the patient’s body.
Medicare, Medicaid, and commercial insurance payers cover code 96372. As of January 1, 2025, Medicare’s reimbursement rate for this injection is between $12.60 and $18.00 (per injection), depending on the MAC locality and facility.
Continue reading as we explain how CPT code 96372 can be reported alone or as part of another (and a more significant) procedure.
Scenarios Where CPT Code 96372 is Applicable
If you were wondering about the correct use of CPT code 96372, let us put your mind at ease. In this section, we will look at some real-world examples where the code is perfectly applicable.
Earlier, we mentioned that you may report code 96372 if you administer a therapeutic drug (except chemotherapy injections), a preventive medicine (except vaccines/toxoids), or a diagnostic dye. So, let’s look at one practical scenario for each to understand CPT code 96372’s appropriate application.
Intramuscular Administration of an Antibiotic for Pneumonia
We will start with reporting CPT code 96372 for prophylactic and therapeutic reasons. Now, imagine that an elderly patient visits the physician’s office and is diagnosed with pneumonia. Her age and weakened immune system make immediate treatment compulsory, as slow treatment could prove to be fatal.
The physician decides to treat her pneumonia with an antibiotic like ceftazidime, ceftriaxone, and aztreonam, which he administers directly to her deltoid muscle in the upper arm for immediate effect (the bloodstream quickly absorbs the drug). While primarily administered to treat pneumonia, the antibiotic will also serve a prophylactic or preventive function against bacterial infections like pneumonia.
Since the physician himself administered the injection intramuscularly and for therapeutic and prophylactic reasons (to treat and prevent pneumonia), CPT code 96372 will be reported.
Naltrexone Injection Administration for Substance Abuse Treatment
Our next example explains how CPT code 96372 can be used to report therapeutic drug administration. Consider that a patient visits a rehabilitation center and receives treatment for substance abuse (alcohol and opioid addiction). The attending physician injects naltrexone (available as Vivitrol in the USA) into the patient’s gluteal muscle (buttocks) once every four weeks. The drug acts as a blocker, reducing the substances’ euphoric effects and helping the patient stay drug-free.
In this case, the physician will report CPT code 96372 because a therapeutic drug (naltrexone) was administered intramuscularly (gluteal muscle) directly by the physician.
Injecting Contrast Material During Radiographic Examination
Our third and last example justifies CPT code 96372’s application for reporting the subcutaneous administration of a diagnostic dye/agent. Imagine that a patient was ordered to undergo lymphangiography to diagnose possible diseases or disorders in the lymphatic system, such as lymphoma and lymphedema.
However, this radiographic examination cannot be done without injecting dye or contrast material into the subcutaneous tissue. The dye makes the lymphatic vessels and lymph nodes visible on the X-ray and MRI imaging, helping the physician detect blockages, lesions, lumps, or leaks. Therefore, the physician supervises the subcutaneous administration of the contrast material before lymphangiography.
Note that the Centers for Medicare and Medicaid Services (CMS) does not allow separate reporting of CPT code 96372 in this case, even though the physician oversaw the subcutaneous administration of a dye for diagnostic purposes, because the injection is considered part of lymphangiography (bundled billing).
Reasons for CPT Code 96372 Denial
Insurance claim denials can disrupt a healthcare practice’s revenue cycle, decreasing the cash inflow and adversely affecting clinical operations. While denials are inevitable, the rate at which they are triggered can be reduced if practices grasp the reasons behind their occurrence.
We have identified and listed some common reasons for CPT code 96372-related denials. Take a look!
- Reporting the code when the injection was not administered by the physician or under his supervision.
- Billing the injection separately when its need was established in a previously occurring evaluation and management (E/M) visit.
- Administering the injection twice without proper documentation or modifiers.
- Assigning this code when the substance administered via the syringe was a vaccine. You should use the CPT vaccination code range 90460- 90593 for this.
- Using CPT code 96372 when the substance injected into the patient’s body was a chemotherapy treatment drug. You must use CPT codes 96401 and 96402 instead. These codes suggest that the chemotherapy drug was administered subcutaneously or intramuscularly.
- Reporting the code when the place of service was an inpatient hospital or an emergency room. This is because injections administered at these places are bundled into the main procedure and not eligible for a separate reimbursement.
- Using a diagnosis code that does not support CPT code 96372. In other words, the patient’s condition does not necessitate therapeutic, diagnostic, or prophylactic drug administration.
- Failing to document the administered substance, its HCPCS code, and the dosage when the drug and injection are billed on the same claim form.
CPT Code 96372 – Billing & Reimbursement Guidelines
Now that you know the reasons for CPT code 96372-related denials, let’s consider some billing best practices that will improve your chances of filing clean claims on the first try.
Bill 1 Unit of Service per Drug
You must bill 1 unit of CPT code 96372 even if the drug was divided into two syringes and administered one after another. This is because Medicare only reimburses one initial drug administration.
So, you will report one unit of CPT code 96372 and another unit of code 96372 with modifier 59 (to explain a distinct procedure) if you administered two different drugs (with two distinct HCPCS codes) and the combined dosage was split into three syringes. Your coding will look like this: 96372, 96372-59
Maintain Proper Documentation
You must document every detail of the procedure and submit it with the claim form as supporting evidence. The documentation will help the insurance payer establish the medical necessity of the injection and understand the circumstances under which it was administered. Therefore, your documentation should include the following:
- The patient’s complete medical history
- Diagnostic test reports
- Referral letter
- Clinical notes for previous related procedures and injection administration
- Notes explaining the reason(s) for separate billing if code 96372 was inherently part of a larger procedure.
Inject the Dose in Direct Supervision of a Physician
CPT code 96372 should only be reported if the physician administers the injection himself or guides a nurse or an assistant under his supervision. It ensures the highest safety standards, as the physician will be present to manage the situation if the patient experiences an allergic reaction to the drug.
Report the Correct HCPCS Code for Drugs or Biologicals
You must ensure HCPCS coding accuracy when reporting CPT code 96372 to inform the payer which drug or biological was administered during the procedure. It also helps the payer determine the dosage given to the patient, as each HCPCS code for drugs specifies the lowest common denominator of the dosage amount.
Use the Appropriate Modifiers when Billing NOC Drugs
Modifiers must be appended when needed with CPT code 96372 and its corresponding NOC drugs to give the insurance payer more context. The most commonly used modifiers with CPT 96372 include 59, LT, RT, 76, and 77. In contrast, modifiers JW and JZ are usually appended with NOC drug codes to explain the amount of drug that was used or discarded.
Adhere to Payer-Specific Billing Requirements
Billing requirements and reimbursement guidelines vary across payers. To ensure compliance, you must carefully review each payer’s specific rules on billing CPT code 96372 before creating and submitting claims. You can also reach out to the insurance payer over call to clarify your doubts, ensure clean claim submission, and prevent payment delays or denials.
Summary
Let’s recap what we discussed in this guide and leave you with the key takeaways. We started our blog with a comprehensive description of CPT code 96372 to explain that this code is reported for intramuscular or subcutaneous administration of a substance for therapeutic, prophylactic, or diagnostic reasons.
Next, we considered its real-world applications, such as treating and preventing pneumonia, treating alcohol or opioid addiction, and diagnosing lymphatic conditions. We also listed the possible reasons for receiving a CPT code 96372-related denial and shared some billing best practices to help you receive reimbursement against this code without any delays.
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