Do you know how to bill for extended IV infusion services? If not, this is your sign to familiarize yourself with the add-on CPT code 96366! Many healthcare providers face claim denials simply because they don’t fully understand when and how to use this code.
Intravenous (IV) therapy has become increasingly popular due to its proven clinical efficacy. The numbers speak for themselves! In 2019 alone, 83% of patients in the U.S. received some form of IV therapy or infusion.
However, with the rise in IV therapies, it is no surprise that insurance payers have also tightened their scrutiny. You must report everything about this service, including additional hours of infusion. That’s why today, we will discuss CPT code 96366 in detail.
CPT Code 96366 – Description
As mentioned in the intro, CPT code 96366 is an add-on code for IV treatment. Simply put, it reports each additional hour of intravenous medication infusion after the initial hour, which is reported by CPT code 96365.
Like all other CPT codes, the American Medical Association (AMA) maintains this code. Specifically, it covers the following types of infusions:
- Therapeutic
- Prophylactic
- Diagnostic
However, it also has some limitations. You cannot use CPT code 96366 for chemotherapy infusions or the administration of highly advanced drugs or biologic agents. These medications require different codes due to their specialized nature.
Scenarios Where CPT Code 96366 is Applicable
Here are three specific scenarios to help you understand the correct application of CPT code 96366:
IV Infusion to Treat Moderate Thrombocytopenia in Pregnancy
Did you know that thrombocytopenia (a platelet count below 150,000) affects up to 10% of pregnant women? These patients often require IV infusions to prevent excessive bleeding during delivery. So, for our first scenario, let’s consider the case of a 34-week pregnant woman with a moderate case of thrombocytopenia.
She arrives at a primary clinic with complaints of frequent nosebleeds and prolonged bleeding from cuts. The doctor evaluates her condition, reviews her medical history, and conducts several tests, including a complete blood count (CBC), to identify the cause. The results reveal a low platelet count (28,000 per microliter of blood).
The doctor decides to administer intravenous immunoglobulin (IVIG) over 3 hours to stabilize her platelet levels. He then reports the first hour of infusion with CPT code 96365 and uses CPT code 96366 to report each additional hour.
IV Fluids to Rehydrate a Patient
Heat-related emergencies have become more common in the U.S. Did you know that untreated heat exhaustion can lead to heat stroke, which claimed around 2,300 lives in 2023? IV fluids are a common treatment for this condition.
So, for our next example, suppose a 25-year-old man arrives in the emergency department due to exercise-related heat exhaustion. He is severely dehydrated and unable to swallow water or medication due to nausea and vomiting.
The healthcare provider initiates an IV infusion with electrolytes to rehydrate him. This infusion lasts for 3 hours. After billing the first hour with CPT code 96365, the doctor reports each additional hour with CPT code 96366.
IV Antibiotics to Treat Severe Cellulitis in a Patient with Eczema
The risk of cellulitis (a serious bacterial skin infection) is higher in patients with skin wounds. While physicians typically prescribe oral medications for this condition, IV administration is sometimes necessary to reduce the infection.
Let’s say a 23-year-old woman with atopic dermatitis (eczema) is admitted to the hospital with a severe case of cellulitis. She has a high fever and pus-filled blisters all over her left leg. After evaluating her condition and recognizing the severity of the infection, the physician decides to administer antibiotics like cefazolin or cefuroxime via IV.
The drip runs for 3 hours. The billing team reports each additional hour after the first one with CPT code 96366.
CPT Code 96366 – Billing & Reimbursement Guidelines
CPT code 96366 may seem quite simple with the scenarios we provided above. However, you can still face denials if you file claims without knowing the code’s billing requirements. Here is how you can file clean claims for extended IV infusion:
Use CPT Code 96366 Only as an Add-On Code
We have emphasized this multiple times! CPT code 96366 is an add-on code to CPT code 96365. Hence, you cannot bill it separately. In simple words, use it only to report extended infusion time after the first hour. This takes us to the next point!
Follow the Time Requirement
What if the IV infusion only lasted for 1 hour and 45 minutes? Can you still report CPT code 96366?
Let’s face it! IV infusions don’t always end exactly at the one-hour mark. Sometimes, they run slightly over or under 60 minutes. This can make coding quite tricky! So, if you have ever missed out on some reimbursements due to this confusion, let us clarify the minimum time requirements for this code.
You can use CPT code 96366 when the additional infusion time exceeds 30 minutes beyond the first hour. This means the minimum threshold to bill for the add-on code is 31 minutes or more after the initial hour.
For example, if the infusion lasted 2 hours and 35 minutes, report the first hour with CPT code 96365 and use CPT code 96366 twice to bill for the additional time (1 hr and 35 mins).
Avoid Using Modifiers with CPT Code 96366
Since CPT code 96366 is an add-on code, avoid using any modifier with this code. Otherwise, insurance companies will deny your claims. To explain unusual circumstances during IV infusion, add the appropriate modifier to the primary code (CPT code 96365).
Document the Medical Necessity and Time
Insurance companies may require justification for prolonged IV infusions. Therefore, you must document the clinical reasons (dehydration, immune disorders, or severe infections) for extending the infusion beyond one hour.
Additionally, you must record the exact infusion time (start and stop times) in the patient’s medical record. In simple terms, your documentation should support the use of CPT code 96366.
Verify Payer-Specific Policies for Coverage
Finally, check each payer’s coverage policy for IV infusion. For example, Medicare only covers non-self-administered infusions of FDA-approved drugs.
Summary
Everyone knows that IV infusions rarely wrap up in exactly one hour. That’s why you need add-on codes like CPT code 96366 to bill for the additional time. This particular code helps to report each extra hour of IV infusion after the first, which is typically billed with CPT code 96365.
While the code may seem straightforward, many healthcare providers and practices make errors due to unclear requirements. To help you avoid the same consequences — claim denials and underpayments — we have broken down exactly how and when to use CPT code 96366.You can follow our guide to submit clean claims. However, if you are tired of constant denials and drowning in paperwork, consider letting a professional handle your coding complexities. Many companies, including MediBillMD, offer comprehensive medical billing services to help reduce your administrative workload.
