Are you facing claim denials for intravenous infusions? Don’t worry, you are not alone. Infusion claims often confuse billers due to their intricate billing requirements and guidelines. One frequently used code is CPT code 96367.
That is why we have created this detailed guide. By the end of this guide, you will have all the information you need to file this code correctly. So, let’s start.
CPT Code 96367 – Description
CPT code 96367 is defined as:
“Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour (list separately in addition to code for primary procedure).”
To make things clear, let’s discuss it in more detail.
Code 96367 is an add-on infusion code. It is used when substances and medications are delivered to the patient intravenously for treatment, preventive, or diagnostic purposes. Two things are vital to note here:
- Code 96367 is an add-on code and cannot be used independently. It must always be used in conjunction with other primary and initial service codes, such as 96365 or 96374. Additionally, this code is reported for the administration of secondary drugs.
- The code must be used once for each sequential infusion. Plus, the time limit of “up to 1 hour” simplifies the time-based billing for billers. It is not necessary to meet the entire 1-hour criteria. You can use 96367 for infusions that last between 16 minutes and 1 hour. This eliminates the need for using modifier 52. Infusions that last less than 15 minutes are classified as IV pushes and require different CPT codes for billing.
Another essential point that you must remember while filing claims is that CPT code 96367 cannot be used for chemotherapy or other highly complex drugs or biologic agents. Chemotherapy IV infusions use a separate CPT coding structure, which usually ranges from 96413 to 96417.
However, the initial drug administered to the patient can be a chemotherapy drug. Therefore, code 96367 can also be used in conjunction with initial chemotherapy infusion codes like 96413.
Scenarios Where CPT Code 96367 is Applicable
Knowing exactly when to apply this code can prevent billing errors and ensure proper reimbursement. Below are a couple of clinical situations where you can use CPT code 96367:
Administration of IV Painkillers
Suppose a patient is undergoing chemotherapy for breast cancer that has spread to other parts as well. Due to this, the patient is experiencing severe pain in the bones. The physician decides that the patient needs to be administered strong painkillers after chemotherapy. The nurse first gives Doxorubicin hydrochloride through an IV for over 45 minutes as the primary cancer treatment. To help with the bone pain, the nurse then administers Denosumab. This second medicine is given through the same IV line.
Eventually, the medical billing department assigns codes and submits the claim for payment. In this case, CPT code 96367 is applicable for administering Denosumab.
Sequential Antibiotic Administrations
Suppose a male patient visits a dermatologist. He has a severe skin infection. The patient has already tried several oral medications, which showed little to no effect. The physician decides to administer strong IV medications to combat the disease. Initially, an antibiotic is administered intravenously for 1 hour. This is followed by the infusion of another secondary antibiotic drug via the same line.
In this scenario, the biller can bill the second drug administration via CPT code 96367, accompanied by a primary code.
Applicable Modifiers for CPT Code 96367
To make your claims more accurate and get fair reimbursement, you must append appropriate modifiers to the procedural codes. The following modifiers are used frequently with CPT code 96367:
| Modifier | Description | When To Use It |
|---|---|---|
| 59 | Distinct Procedural Service | Used when the infusion service is distinct and separate from other services performed on the same day. |
| LT | Left Side | Used to explain that the IV catheter was inserted in a vein on the left side of the body (arm, wrist, hand). |
| RT | Right Side | Used to explain that the IV catheter was inserted in a vein on the right side of the body (arm, wrist, hand). |
Please note that JW and JZ modifiers, which denote the amount of drug or biological that is discarded, and that there were no discarded amounts, respectively, are added to the HCPCS code for drug (e.g., J2357) and not the IV infusion CPT codes. Hence, we have not included them in our table.
CPT Code 96367 – Billing & Reimbursement Guidelines
Was your claim for CPT code 96367 denied due to a lack of medical necessity or any other reason? Here is what you should consider to bill it accurately:
Documentation
Insurance payers require justification for IV infusions. Therefore, you must provide comprehensive documentation with your claims to justify the medical necessity. You should always append the following details to your 96367 claims:
- Precise start and stop times for each sequential infusion.
- Clear identification of different drugs or substances administered.
- Medical necessity justification for sequential administration.
- Documentation of patient monitoring during infusion services.
- Notation of any adverse reactions or complications.
- Flush procedures between sequential administrations.
Bundled Services
Medical billers must note that some services and equipment are included in the reimbursement for CPT code 96367. Therefore, according to the CMS guidelines, the following services and equipment are not separately billable.
- Use of local anesthesia
- IV start
- Access to an indwelling IV, subcutaneous catheter, or port
- Flush at the conclusion of the infusion
- Standard tubing, syringes, and supplies
- Preparation of chemotherapy agent(s)
Reimbursement Amount
The reimbursement amount for CPT code 96367 varies based on location and facility settings. The national average Medicare reimbursement for 96367 is $26.52 for non-facility settings. For facility settings, the exact price data is not available.
To check the exact reimbursement amount for your MAC locality, you can use Medicare’s PFS Lookup Tool.
Wrapping Up
CPT code 96367 is a frequently used code for subsequent intravenous infusions. It is an add-on code that must be used in conjunction with a primary infusion code. You must support your claims with appropriate modifiers and comprehensive documentation for fair reimbursement.
If you find all this confusing and hard to manage, you can always rely on our billing experts for premium internal medicine billing services.
