Ultimate Guide to CPT Code 96375

Medical billers and coders face numerous challenges when filing insurance claims. Small mistakes in CPT code selection can lead to claim denials and a loss in revenue collection. The codes for therapeutic injections and infusions are particularly confusing. Within this category, CPT code 96375 is widely used, yet often billed incorrectly.

That is why our experts have compiled this comprehensive guide on CPT code 96375. In this guide, we will discuss everything related to 96375, including applicable modifiers, real-world scenarios, and billing guidelines. So, let’s start. 

CPT Code 96375 – Description

CPT code 96375 is defined as “Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous (IV) push of a new substance/drug.”

96375 is an add-on code. This means it cannot be reported alone in a claim and must be used with another primary code. It falls under the broader category of “Therapeutic, Prophylactic, and Diagnostic Injections and Infusions” in the CPT coding manual. However, CPT code 96375 cannot be used for chemotherapy drug administration and other highly complex drug or biologic agent delivery.

Key characteristics of code 96375 include:

1. It represents an IV push administration lasting 15 minutes or less
2. Must involve a new substance or drug different from the initial injection
3. It is an add-on code that can only be reported with an appropriate primary code
4. Forms part of a structured hierarchy of infusion and injection codes

An important thing to note in the code definition is the phrase “each additional sequential intravenous push of a new substance/drug”. This phrase indicates that 96375 applies exclusively to subsequent administrations after documenting an initial service.

Scenarios Where CPT Code 96375 is Applicable

Let’s look at some real-world scenarios where this code can be used. This will help you better understand the practical application of 96375.

Multiple Drug Administration

When a patient receives more than one medication through IV push during the same encounter, CPT 96375 is used for each additional drug after the initial one. For instance, if a patient gets an antibiotic through IV push followed by anti-nausea medication, the first medication requires the

primary code (typically 96374), while the anti-nausea drug needs code 96375.

Emergency Department Administration

If you have ever been to an emergency room, you must have witnessed how patients get multiple medications one after another. In this scenario, after coding the first medication administration, each subsequent new medication delivered via IV push requires code 96375.

Post-Surgical Pain Management

After a major surgery, patients are often given sequential IV pushes to help with the pain. In this situation, the first IV is coded with the primary code, and other additional pain-relieving IV pushes are billed with CPT code 96375. 

However, it is important to note here that CPT code 96375 specifically applies to new substances or drugs. If sequential IV pushes of the same medicine are provided, using CPT code 96376 is more appropriate. But only if administered more than 30 minutes after the initial push of the same substance.

Applicable Modifier for CPT Code 96375

Modifiers are two-digit codes that are appended to CPT codes in the claim. They provide additional information about the procedure and the circumstances in which it was performed. Modifiers can have a significant impact on the reimbursement amount. The following modifier can be used with CPT code 96375:

Modifier	Description	Application
59	Distinct Procedural Service	Signals that a service is separate or independent from other services performed on the same day. Used when the IV push occurs at a different anatomical site, during a separate encounter, or is distinct.

CPT Code 96375 – Billing & Reimbursement Guidelines

To secure the appropriate payment for CPT code 96375, you must follow the specific billing guidelines set by Medicare, Medicaid, and other commercial insurance companies. The following are some key things to consider while filing a claim for 96375:

Hierarchical Structure and Primary Code Requirements

As an add-on code, CPT 96375 cannot be billed alone. It must be reported with an appropriate primary code. In most cases, the following primary CPT codes are used:

1. 96365 (IV infusion, initial up to 1 hour)
2. 96374 (IV push, single or initial substance/drug)
3. 96413 (Chemotherapy administration, IV infusion, up to 1 hour)

The selection of primary code is also essential for the accurate billing of 96375. According to the CPT guidelines, infusion and injection services have the following hierarchical structure:

1. Chemotherapy services (highest)
2. Therapeutic, prophylactic, and diagnostic services
3. Hydration services (lowest)

Documentation Requirements

To support your 96375 claim, you must attach all the necessary documents with your claim. Your medical records should include:

1. The specific name of each drug administered
2. Dosage of each medication
3. Route of administration (IV push)
4. Sequence of administration
5. Time of administration for each drug
6. Medical necessity for each medication
7. Physician’s order for each medication

Common Billing Errors and Denial Reasons

To increase your chances of successful billing, try to avoid the following common billing errors and denial reasons:

1. Billing without a required primary code
2. Failure to use appropriate modifiers when needed
3. Insufficient documentation of medical necessity
4. Incorrect sequencing of codes based on the hierarchy
5. Missing or inadequate documentation of medicines administered
6. Bundling, unbundling, and upcoding

Bundling Considerations

According to Medicare guidelines, several services are included (bundled) with CPT code 96375 and should not be billed separately:

1. Use of local anesthesia
2. IV start
3. Access to an indwelling IV, subcutaneous catheter, or port
4. Flush at the end of the infusion
5. Standard tubing, syringes, and supplies
6. Preparation of medications

Wrapping Up

CPT code 96375 represents the sequential intravenous push of a new substance or drug. It must be billed with careful planning and a precise understanding of the requirements. Even small mistakes can lead to claim denials. 

By following the guidelines provided in this blog, healthcare providers and medical billers can ensure accurate claim submissions. To improve your claims acceptance rate and revenue collection, connect with our billing experts for the best internal medicine billing services.