Navigating the complexities of medication administration is a daily reality for general physicians and specialists alike. Accurate coding and timely reimbursement are crucial for the financial health of your practice. It allows you to focus on what matters most: patient care.
This ‘Ultimate Guide to CPT Code 96365’ is designed to be your go-to resource for understanding and correctly applying this pivotal intravenous infusion code.
We will break down the nuances of 96365, from its specific descriptor and clinical scenarios to applicable modifiers and billing guidelines.
Equip yourself with the knowledge to confidently bill for initial intravenous (IV) infusions and optimize your practice’s revenue cycle.
CPT Code 96365 – Description
CPT code 96365 is from the ‘Therapeutic, Prophylactic, and Diagnostic Injections and Infusions’ code range and is maintained by the American Medical Association (AMA). It covers the administration of an intravenous infusion of a medication or other substance for the initial one hour. Physicians often order this procedure to diagnose, treat, or prevent a disease or condition.
Please note that CPT code 96365 does not cover the intravenous infusion of chemotherapy drugs or complex substances/biologic agents.
Scenarios Where CPT Code 96365 is Applicable
Let’s review the following clinical scenarios to understand the proper application of CPT 96365:
Micronutrient IV Infusion for Treating Vitamin Deficiencies
Suppose this: A 32-year-old malnourished woman constantly feels fatigued and starts to notice visible changes in her skin and hair. She visits her internist for a suitable treatment. Her internist orders a complete blood test to check for vitamin B12, C, and D deficiencies.
But while waiting for the blood test, the woman starts to feel dizzy and nearly collapses on the office floor. The internist, with the help of a registered nurse, administers micronutrients (a solution of essential multivitamins and minerals) via intravenous infusion into her body for up to an hour.
Thus, CPT code 96365 is reported for the therapeutic IV infusion.
Prophylactic Antibiotic Infusion Before Surgery
Picture this: A 60-year-old patient visits the hospital for an elective angioplasty. As a standard protocol, the cardiologist orders a prophylactic intravenous antibiotic, such as cefazolin, before the surgery to prevent surgical site infection.
Thus, an available internist administers the cefazolin infusion in the preoperative holding area. During the first hour of the infusion, he also monitors the patient for any adverse reactions.
He reports the initial hour of prophylactic IV antibiotic administration with CPT code 96365.
Applicable Modifiers for CPT Code 96365
Here’s a list of all possible modifiers that may apply to the initial intravenous infusion for up to an hour:
Modifier 59 & X{EPSU}
You may append modifier 59 or its subcategory modifiers X{EPSU} to the CPT code 96365. Here’s when:
Use 59 when the infusion is distinct and separate from other treatments rendered on the same day. OR append the following for enhanced specificity if they explain the case better:
XE – If the provider administers an infusion at a separate encounter.
XP – If a different provider administers it.
XU – If the IV infusion does not overlap with the main components of the initial service.
These modifiers enable you to bypass payment issues due to the bundling of services as per the National Correct Coding Initiative (NCCI) edit. However, do not use it to receive higher or unnecessary reimbursements. Overusing or misusing these modifiers can land you in hot water, such as audits, financial penalties, reputational damage, and lawsuits.
CPT Code 96365 – Billing & Reimbursement Guidelines
Do you want to supercharge your collections for the initial intravenous infusion? Discussed below are the CPT 96365 billing and reimbursement guidelines:
Focus on Documenting the Time
Accurate documentation of the infusion duration is essential for reporting the CPT code 96365. The documented time should reflect the actual duration from initiation to completion.
Do Not Use CPT 96365 for Subsequent Infusions
What happens when you intravenously infuse multiple drugs one after the other into the same patient? Can you report CPT code 96365 several times? No! You report the CPT 96365 to bill the initial hour of the first drug.
Report CPT 96366 for extra hours of infusion beyond the initial hour and CPT 96367 for the additional sequential infusion of a new drug for up to an hour.
Do Not Use CPT 96365 for Concurrent Infusions
Now, you may be wondering what happens in the case of concurrent infusions. But before explaining it, let’s first understand what it is.
It occurs when the healthcare provider infuses a different drug or substance into the patient during the initial infusion. Simply put, it is the simultaneous administration of various substances.
If this happens, you cannot report CPT code 96365 for concurrent infusions. There is a separate code for it, i.e., CPT code 96368.
Demonstrate Medical Necessity
The reimbursement against CPT code 96365 depends on the procedure’s medical necessity. Therefore, you should ensure detailed documentation.
It must include the patient’s symptoms, diagnoses, service date, procedure start and end time, medication/drug information, and dosage. Your documentation must also mention the adverse effects (if any) that the patient experiences during the infusion.
Pair 96365 with the Correct HCPCS Code to Separately Bill the Drug
You must remember that CPT code 96365 only covers the intravenous administration of a therapeutic, diagnostic, or prophylactic drug and not the drug itself. Medicare, Medicaid, and commercial payers allow you to bill the drug separately for fair reimbursement. However, you must use the most appropriate HCPCS code for the drug/substance administered via IV infusion for the claim to be processed and paid.
Can We Bill CPT Codes 96365 and 96413 Together?
Yes, you can report CPT codes 96365 and 96413 together as both codes refer to different intravenous infusion therapies. CPT code 96365 reports IV infusion of non-chemotherapy drugs, whereas CPT 96413 specifies IV infusion of chemotherapy drugs. So, according to the NCCI edits, the codes can be reported together if “administrations occur at separate intravenous access sites”. Thus, you must provide detailed documentation that supports each infusion procedure as distinct and separately identifiable.
Additionally, payer policies may vary. Some payers may not reimburse separately for both CPT codes if the physician administers these on the same day. Hence, you should review the specific payer policies before reporting these codes or appending modifier 59.
Summary
Well, we’ve left no stone unturned in this ultimate guide to CPT code 96365! It is time to wrap up. But, before concluding, why not quickly revisit all the key takeaways?
So, here we go!
First, we explained that CPT 96365 covers the administration of an intravenous infusion of a medication or other substance for the initial hour. Second, we shared some clinical scenarios where this code can be reported for billing accuracy. Next, we discussed the applicable modifiers, including 59, XE, XP, and XU. Finally, we explained the billing and reimbursement guidelines related to the CPT 96365.
The BONUS? We answered the frequently asked question on the web, ‘Can We Bill CPT Codes 96365 and 96413 Together?’. Hopefully, all these details will help you master the billing of CPT code 96365. However, if you want professional help, you can outsource internal medicine billing services to MediBillMD.
