cpt code 96365

CPT Code 96365 Description, Guidelines, Reimbursement, Modifiers & Example (2022)

CPT code 96365 is a billing code for medical procedures, treatment, and diagnostic injections or infusions (for chemotherapy and other highly complex drugs or highly complex biologicals). Excluding dosing.

Intravenous Therapeutic Infusions, CPT Code (96365 – 96368) – A bill for services when a physician administers a therapeutic drug intravenously using consumables such as tubes, infusion pumps, cannulas, and needles.

Infusion: Administration of diagnostic, prophylactic, therapeutic fluids through an IV and/or drugs administered over time. (e.g., banana bag, heparin, nitro-glycerine, antiemetics, antibiotics, etc.) 

 • IVPB (intravenous infusion): The term infusion is used because it is a method of administering drugs through an existing intravenous tube inserted into a patient’s vein. IV drugs are usually mixed with a small amount of a compatible liquid, such as saline.

Common Drugs are Used for intravenous therapy according to the patient’s condition.

Infusion therapy may also be performed to deliver nutrition, as well as many types of medications, including:

  • antibiotics
  • antiemetics
  • antifungals
  • antivirals
  • biologics
  • blood factors
  • chemotherapy
  • corticosteroids
  • growth hormones
  • immunoglobulin replacement
  • immunotherapy
  • inotropic heart medications

CPT Code 96365 Description

The following are CPT codes for Intravenous Infusions and the 96365 CPT code description.

CPT code 96365 – The intravenous infusion will be reported for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour.

cpt 96365

96366 – The intravenous infusion will be reported for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (in addition to 96365).

96365 cpt code

96367 – The intravenous infusion will be reported for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug or substance, up to 1 hour ( in conjunction with 96365, 96374, 96409, 96413).

96365 cpt code description

96368 – Intravenous infusion for therapy, prophylaxis or diagnosis; concurrent infusion (in conjunction with 96365, 96366, 96413, 96415, 96416))

96368

CPT Code 96365 Reimbursement

The cost and RUVS of colonoscopy CPT code 96365 – 96368 are as follows:

CPT Code 96365 – Facility: Cost $69.21 with RVU 2.00. Non-Facility: Cost $69.21 with RVU 2.00.

CPT 96366 – Facility: Cost $21.46 with RVU 0.62. Non-Facility: Cost $21.46 with RVU 0.62.

CPT 96367 – Facility: Cost $30.80 with RVU 0.89. Non-Facility: Cost $30.80 with RVU 0.89.

CPT 96368 – Facility: Cost $20.76 with RVU 0.60. Non-Facility: Cost $20.76 with RVU 0.60.

CPT Code 96365 Modifiers

The following is a list of modifiers that are applicable with CPT code 96365 – 96368:

22,52,59,79, AS, KX, PD, Q6, XE, XP, XU.

Modifier 22 can be applied if the service takes extra time to complete (96365-96368). Modifier 52 applies with (CPT code 96365 – 96368) when partial service is provided. 

Modifier 59 applies where other procedures not normally billed together on the same service date are performed with these services, and Modifier 59 is appropriate. Modifier 79 (96365-96368) is added if the service provided in the global period is not related to the original base service. 

CPT code 96365 – 96368 is added to the AS modifier when the service is provided by a nurse practitioner professional to a physician assistant, nurse practitioner, or surgical assistant. A PD modifier is added when a diagnostic or related non-diagnostic item or service is provided to a patient admitted to the hospital within three days.

Drugs used for infusion therapy are reimbursable when provided by a physician or facility. 

Common drugs & nutrients used for IV therapy:

  • J0120 – Injection, tetracycline, up to 250 mg
  • J0121 – Injection, omadacycline, 1 mg
  • J0122 – Injection, eravacycline, 1 mg
  • J1020 – Injection, methylprednisolone acetate, 20 mg
  • J1030 – Injection, methylprednisolone acetate, 40 mg
  • J1040 – Injection, methylprednisolone acetate, 80 mg
  • J1050 – Injection, medroxyprogesterone acetate, 1 mg
  • J3420 – Injection, vitamin b-12 cyanocobalamin, up to 1000 mcg
  • J7060 – 5% dextrose/water (500 ml = 1 unit)
  • J7070 – Infusion, d5w, 1000 cc
  • J7100 – Infusion, dextran 40, 500 ml
  • J7110 – Infusion, dextran 75, 500 ml
  • J7120 – Ringers lactate infusion, up to 1000 cc
  • J7121 – 5% dextrose in lactated ringers infusion, up to 1000 cc
  • J7209 – Injection, factor viii, (antihemophilic factor, recombinant), (nuwiq), 1 i.u.
  • J7210 – Injection, factor viii, (antihemophilic factor, recombinant), (afstyla), 1 i.u.
  • J7211 – Injection, factor viii, (antihemophilic factor, recombinant), (kovaltry), 1 i.u.
  • B4164 – Parenteral nutrition solution: carbohydrates (dextrose), 50% or less (500 ml = 1 unit) – home mix
  • B4168 – Parenteral nutrition solution; amino acid, 3.5%, (500 ml = 1 unit) – home mix
  • B4172 – Parenteral nutrition solution; amino acid, 5.5% through 7%, (500 ml = 1 unit) – home mix
  • B4176 – Parenteral nutrition solution; amino acid, 7% through 8.5%, (500 ml = 1 unit) – home mix
  • B4178 – Parenteral nutrition solution: amino acid, greater than 8.5% (500 ml = 1 unit) – home mix
  • B4180 – Parenteral nutrition solution; carbohydrates (dextrose), greater than 50% (500 ml = 1 unit) – home mix
  • B4185 – Parenteral nutrition solution, not otherwise specified, 10 grams lipids.

Medical Necessity for Intravenous Infusion (ICD 10 codes):

Common conditions for which infusions are administered include weakness, fatigue, mineral & electrolyte deficiencies, infections, etc. 

  • A02.0Salmonella enteritis
  • A02.1Salmonella sepsis
  • A02.20 – Localized salmonella infection, unspecified
  • A02.21 – Salmonella meningitis
  • A02.22 – Salmonella pneumonia
  • A02.23 – Salmonella arthritis
  • A02.24 – Salmonella osteomyelitis
  • D00.00 – Carcinoma in situ of the oral cavity, unspecified site
  • D00.01 – Carcinoma in situ of labial mucosa and vermilion border
  • D00.02 – Carcinoma in situ of buccal mucosa
  • D00.03 – Carcinoma in situ of gingiva and edentulous alveolar ridge
  • D00.04 – Carcinoma in situ of the soft palate
  • D00.05 – Carcinoma in situ of the hard palate
  • D00.06 – Carcinoma in situ on the floor of the mouth
  • E74.810 – Glucose transporter protein type 1 deficiency
  • E74.818 – Other disorders of glucose transport
  • E74.819 – Disorders of glucose transport, unspecified
  • E86.0Dehydration
  • G43.A0 – Cyclical vomiting, in migraine, not intractable
  • G43.A1 – Cyclical vomiting, in migraine, intractable
  • G89.3 – Neoplasm related pain (acute) (chronic)
  • T40.711A – Poisoning by cannabis, accidental (unintentional), initial encounter
  • T40.712A – Poisoning by cannabis, intentional self-harm, initial encounter
  • T40.713A – Poisoning by cannabis, assault, initial encounter
  • T40.714A – Poisoning by cannabis, undetermined, initial encounter
  • T40.715A – The adverse effect of cannabis, initial encounter
  • T40.721A – Poisoning by synthetic cannabinoids, accidental (unintentional), initial encounter
  • U07.1 – COVID-19

CPT Code 96365 Billing Guidelines

Documentation must support a medical need for services. It reflects that the service is medically necessary. 

 Drugs used for intravenous infusion must be adequately documented. CPT Code 96365 and other CPT codes for infusions are time-based, so entering injection start and end times is important. 

CPT Code 96365 is billed for an hour infusion. Only one unit of 96365 is billed per day. You will be charged 96366 for each additional hour. You can charge 8 to 24 units if the documentation confirms the services provided. 

Sequential infusion of the new drug is billed at 96367. You may be charged more than four daily units if supported by documentation. 

If two infusion starts are the same, they will be billed as simultaneous infusions with CPT code 96368. You can only charge one unit per day. 96368. IV therapy can be used in clinics/offices, hospitals, or other facilities. 

Offices and clinics do not pay for supplies and equipment. For hospitals and emergency rooms, equipment, and supplies used for intravenous therapy are billed separately. If services are performed with assessment and management, they will be charged with the appropriate CPT assessment and management code following the documentation. 

CPT Code 96365 Examples

The following are examples of when CPT code 96365 may be billed.

Example 1

Documentation from the ED Physician Notes:

Administered Medications:

19:21 – Drug: Zofran 4 mg Route: IVP; Site: left antecubital

20:54 – Follow-up: IV status: Completed infusion Response: No adverse reaction; Nausea is decreased

19:21 – Drug: morphine 4 mg Route: IVP; Site: left antecubital

20:20 – Follow-up: Response: No adverse reaction; Pain is decreased

19:21 – Drug: NS 0.9 percent 1,000 ml Route: IV; Rate: bolus; Site: left antecubital

20:54 – Follow-up: IV status: Completed infusion

ED Meds Day 1

Zofran
19:21
20:54

4 mg IVP 4 mg complete

Morphine
19:21
20:20

4 mg IVP

4 mg NS
19:21
20:54

1,000 ml IV
bolus
complete

Codes assigned would be CPT code 96365 and 96375. Normal saline (NS) will not be coded due to the Zofran infusing during the entire NS time. The total time for the infusion of Zofran was 93 minutes, well over the initial 31 minutes to qualify to be coded 96365 CPT code.

Example 2

A patient visits the office with fever, cough, chills, and abdominal pain. He is diagnosed with Pneumonia. The physician recommends Rocephin infusion.

The nurse will document the Intravenous infusion time as follows:

Start time: 3:00pm

End Time: 5:00pm

The coder will code it with one unit of CPT code 96365 and one unit of 96366. With Diagnosis Code J18.9.

Example 3

A patient is admitted complaining of diarrhea. An IV is set up to infuse 500mg Flagyl infusion and 1gm ceftriaxone for diarrhea. 

The documentation for this infusion therapy will be as:

Meds
start time
end-time

Flagyl
2:00
4:00

500mg IVPB
4 mg
complete

Ceftriaxone
2:00
3:00

1gm IVPB

The coder will code it as:

96365: 1 unit
96366: 2 units
96368: 1 unit (for concurrent administration)
ICD 10: R19.7

Time documentation is critical because it drives the assignment and accuracy of the CPT coding of infusion services.

Selecting the Correct CPT Code Follow the CPT guidelines and hierarchy to ensure accurate code selection. Each medication administration’s Start and Stop times must be accurately recorded, as this determines the correct CPT code assignment.

Assign the appropriate ICD 10 CM diagnosis code to identify the reason for injection/infusion regardless of the care site. For outpatient coding, the reason for the injection/infusion is the first-listed diagnosis for outpatient visits. Also, code any co-morbid conditions currently under treatment as additional diagnoses.

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