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CPT code is an essential issue in the healthcare industry, and healthcare experts, medical coders, and billing professionals should thoroughly apprehend it. If you work in medical billing or coding, you’re acquainted with medical codes and their significance in ensuring correct compensation, regulatory compliance, and powerful patient record-retaining. In this context, we aim to provide you with a comprehensive know-how of the code and its importance within the healthcare industry by addressing a few regularly requested questions.
CPT code 96372 is for administering subcutaneous or intramuscular injections but not for highly complex drugs, biologics, or chemotherapy. It is commonly used for therapeutic, prophylactic, or diagnostic injections.
- Pain medications
- Allergy medications
- Hormone replacement therapy medications
- Contraceptive injections
96372 CPT code description
CPT code 96372 is described as:
Therapeutic, prophylactic, and diagnostic substances by subcutaneous or intramuscular injection or infusion; single or multiple (e.g., influenza vaccine, antibiotic, pain medication, allergy medication, hormone replacement therapy, contraceptive).
Related article: What is CPT code 73110? Description, Guidelines & Modifiers
Reimbursement for CPT code 96372
CPT code 96372 must meet these criteria for reimbursement.
- A qualified healthcare professional must administer the injection.
- For an injection to be issued, the procedure must be medically required and authorized by a physician.
- Injection requires a sterile technique.
- The injection must be documented in the patient’s medical record.
In addition to the above criteria, CPT code 96372 may be subject to other reimbursement requirements, depending on the payer.
For example, some payers may require that the injection be performed in a specific setting, such as a physician’s office or clinic. Other payers may require that the infusion be for a particular medical condition.
Additional criteria for reimbursement
- CPT code 96372 is typically reimbursed as a single procedure, regardless of the number of drugs or substances injected.
- It must be billed with an evaluation and management (E/M) service on a different day.
- Injection on the same day as minor surgery may be bundled into the surgical code and not separately reimbursed.
A patient receives a weekly insulin injection from their doctor, who records the procedure using CPT code 96372 and bills the patient’s insurance. Approval for reimbursement depends on the patient’s coverage and other requirements. If approved, the patient pays a copay or coinsurance.
Why do CPT 96372 code denials occur?
Insurance companies may deny CPT code 96372 claims due to various common reasons.
- Incorrect or missing coding is a common reason for denial of CPT 96372 claims. Reporting the code correctly with all required modifiers is essential to avoid rejection.
- Some payers may not cover CPT code 96372 for injections that are not medically necessary or for cosmetic purposes.
- If an injection is not deemed medically necessary and ordered by a physician, the insurance company may deny reimbursement.
- A physician must deem procedures medically necessary to be covered by insurance. Cosmetic procedures or non-medically necessary procedures may not be covered. Separate reimbursement may not be allowed if performed on the same day as a minor surgical procedure.
- Specific requirements for reimbursement of CPT 96372 injections, such as particular settings or medical conditions, may need to be met.
If your CPT code claim is denied, review the reason. If you think it’s an error, contact the payer to appeal.
Here are a few tips to help you avoid denials:
- Always verify that you have reported the correct CPT code and modifiers for the service rendered.
- Before administering the injection, ensure the patient’s insurance plan covers it.
- Be sure to document the medical necessity of the injection in the patient’s medical record.
- Always watch for any bundling rules that may apply to CPT code 96372.
- Review the payer’s specific requirements for reimbursement of CPT code 96372.
What are the modifiers for CPT 96372?
The following modifiers may be used with CPT code 96372:
- Modifier 59: Distinct procedural service
It is used to indicate that the injection is a separate service from other treatments that were performed on the same day. For example, if a patient receives an injection and an E/M service on the same day, the injection would be billed with modifier 59 to indicate that it is a separate service.
- Modifier 25: A physician may provide a separate evaluation and management service on the same day as a procedure.
It indicates that a significant, separately identifiable E/M service was performed on the same day as the injection. For example, if a patient comes in for an E/M visit and receives an injection, the E/M service would be billed with modifier 25 to indicate that it is a separate service.
Use modifiers only when necessary to avoid claim denials.