Table of Contents
The CPT code 96372 refers to billing of therapeutic, prophylactic, or diagnostic injections administered subcutaneously or intramuscularly. Medical necessity, thorough reporting, and proper coding of the associated drug are critical to reimbursement. Modifier and record compliance are necessary. The proper use of this code is especially critical to avoid audits. Understanding the scope of coverage and payer requirements guides compliance in billing denial, audit, and revenue loss. The result is billing accuracy.
In the outpatient and physician office setting CPT code 96372 is one of the most common medical billing codes used. It denotes the administration of a therapeutic, prophylactic, or diagnostic injection, whether given subcutaneously or intramuscularly. This code is essential for healthcare providers to receive reimbursement for injectable medications. However, due to the common use of the code in conjunction with drug codes and evaluation and management (E/M) services, it has numerous coverage policies, compliance, and audit issues. Revenue integrity and billing mistakes are predicated on the use of this code and therefore it is important to understand the intricacies of this code.
Understanding CPT Code 96372
Understanding CPT Code 96372
CPT 96372 includes the administration of a therapeutic injection, prophylactic injection, or diagnostic injection subcutaneously or intramuscularly. It is a code that pertains to the actual administration only, but it does not include the cost of the medication. The medication is billed separately, and the appropriate HCPCS Level II J-code must be used. In non-facility settings, it is also the most used in urgent cares, physician offices, outpatient clinics, and other settings. CPT code 96372 cannot be used for intravenous injections or infusions, as those are documented and billed under different CPT codes. Comprehensive documentation of the injection route and the medical necessity is vital to ensure appropriate billing and reimbursement.
Coverage of CPT Code 96372
Medical Necessity Requirements
The principal consideration for coverage of CPT code 96372 is whether the injection was medically necessary. This means that for commercial insurers and for Medicare to pay for an injection, there needs to be a clinical reason, whether for the diagnosis or treatment of the patient’s medical condition. Therefore, the provider must document that the patient has a condition that is being treated, provide a rationale for the injection, and explain how the injection is tied to the patient’s treatment plan. Otherwise, the claim will be denied, and there isn’t likely to be sufficient reason for the injection.
By way of illustration, injections for the purpose of preventive care, treatment of an infection, hormone therapy, pain management, and treatment of a vitamin deficiency are generally covered, provided there is sufficient documentation to support a claim. On the other hand, injections performed for the sake of convenience, or more importantly, for purposes that are not clear medically, there is unlikely to be a reimbursement claim.
Payer-Specific Coverage Policies
Various insurance providers may publish unique coverage policies regarding CPT code 96372. For example, Medicare may consider the injection administration as a separate service and, therefore, may bundle it with other services. Some providers require modifiers when billing the injection in conjunction with an evaluation and management service. There are rules, too, for commercial insurers that relate to the frequency of provider visits, diagnosis coding, and the categories of providers that may be involved in the treatment. These policies are important for healthcare providers to be familiar with to ensure that they are billing accurately and to minimize the likelihood of claim denials.
Bundling and Separate Reimbursement
CPT code 96372 may be, and often is, bundled into another service without payment. For example, if injections are given during a procedure where the injections are considered a part of the service, the procedure may not allow separate reimbursement. In instances where the injection is separate and distinct from other services, it may be billed and reimbursed separately. Most of the time, the appropriate use of modifiers (e.g., modifier 25) conveys that the services are separate and, in fact, different, medically necessary services.
Compliance Considerations for CPT Code 96372
Accurate Documentation Standards
With compliance, it all starts with the documentation. Medical records for an injection should include, at a minimum, the medication administered, the dosage, route of administration, site of injection, date and time, and the identity of the provider. Incomplete documentation in the records may mean that you have not complied with the standards for billing CPT code 96372. If documentation is vague or incomplete, the provider is exposing themselves to a higher risk of audit findings and denial of the claim. It is the provider’s obligation to ensure that documentation is in order, is reflective of the medical necessity, and is conclusive that the injection was actually administered.
Appropriate Use with Evaluation and Management Services
CPT code 96372 is frequently billed together with an evaluation and management service. However, compliance stipulates that the evaluation and management service is separate and substantial. If the patient visit is exclusively for the injection and no other evaluation is done, it’s likely inappropriate to bill any evaluation and management code in addition to CPT code 96372. When substantial evaluation is done, modifier 25 is required on the evaluation and management code to indicate that it’s separate from the injection service. Use of modifiers appropriately is fundamental for compliance and payment.
Appropriate Coding and Billing of Drugs
Accuracy in billing of the drug itself is also a compliance requirement. CPT code 96372 does not represent the administration service; therefore, the drug has to be billed separately using the appropriate HCPCS code. The amount billed must correspond to the amount documented in the patient record. Applying errors, like billing drug quantities incorrectly, using the wrong code, or billing for drugs not given, can lead to compliance violations and repayment requests.
Audit Risks Linked to CPT Code 96372
Concerns of Overuse and Repetition
Due to the uncomplicated nature of coding CPT code 96372, it is frequently over coded or billed incorrectly. An uncharacteristically high use of the CPT 96372 code is an indicator of potential billing abuse and therefore is flagged for payer audits. If, for example, the physician billed for an injection which is considered to be medically unnecessary, the auditor will use the justification and documentation, if available, to support the billed procedure. It is apparent to payers that unsubstantiated coding is an honest attempt at fraud, and it increases the risk of being flagged for coverage.
Billing When Medical Justification Is Absent
One of the most common risks of an audit is billing CPT 96372 when there is no medical justification for the procedure. An auditor will review diagnosis codes and documentation to determine if an injection was necessary to treat the patient. If the patient’s condition or the treatment plan does not support the need for the injection, an auditor will flag the claim and request repayment.
Improper Use of Modifiers
One of the biggest risks and causes of an audit is the misuse of modifiers, particularly 25. Some billers will use modifier 25 without determining if the evaluation and management service is billed separately. The risk modifiers pose to payers is that they will likely deny payment for the claim. Without the appropriate documentation, the claim will be flagged.
Incomplete and Missing Documentation
Failure to provide complete and accurate documentation on a medical record is a frequent cause for negative findings in audits. Auditors consider a record incomplete without the medication name, dosage, route, and medical necessity for the claim to be processed. Records are critical in defending a claim during an audit.
Recommendations to Optimize Reimbursement and Mitigate Risks
Implementation of thorough documentation and billing processes in the system is the only mechanism health providers can utilize to eliminate the possibility of a compliance or audit issue. It is imperative to train billing personnel on the appropriate use of CPT code 96372 and to provide frequent internal audits to resolve problems before external audits. To enhance compliance and reimbursement, updated coding manuals, the latest payer policies, and accurate and thorough documentation for each patient are a few of the things that should be used. In addition to the processes above, effective communication across the clinical and billing departments is critical. When accurate documentation is available to the provider and appropriate coding is used by the billing personnel, the likelihood of an audit or claim denial is greatly minimized.
Conclusion
Reporting therapeutic, prophylactic, and diagnostic injections using CPT code 96372 is relevant when the injection is administered via subcutaneous or intramuscular routes. Although the code is frequently used, its coverage criteria, and compliance requirements are extremely strict as the code is heavily audited. Meticulous documentation, proper billing of the drug, accurate application of modifiers, and compliance with policy requirements of the payers are essential to achieve correct reimbursement. Not adhering to requirements can result in claim denials, audits, and loss of money. If health care professionals understand coverage rules, and keep, as best as possible, the risk of audits to a minimum, they can, and should, preserve revenue and continue to deliver quality care to their patients.
Make An Appintment With A2ZFAQs
CPT code 96372 is considered an injection administrative code. It is a code used for injections that are considered therapeutic, prophylactic, or diagnostic, and for injections that are administered, either by subcutaneous or intramuscular means. CPT 96372 does not include the drug that is being administered, and that will need to be billed separately, using a HCPCS drug code.
CPT code 96372 can be billed with E/M service if the provider did an extended evaluation. In this situation, CPT code 25 should be billed in conjunction with the CPT E/M code to show that the E/M service is separate and unrelated to the injection service.
CPT code 96372 is not inclusive of the drug that was administered through the injection. Therefore, the drug is to be billed separately using the applicable HCPCS Level II code and the drug and its dosage should correlate with the patient’s medical records.
Some of the frequent reasons include misuse/abuse, medical necessity, modifier misuse, and insufficient documentation. Each auditor reviews the records to ensure that the injection was warranted, thoroughly documented, and billed to the correct payer.
The documents include patient diagnosis, name of medication, dosage, route of administration, injection site, date and time, and name of the provider. To mitigate the risk of audits, the documentation must be complete and accurate in order to receive proper reimbursements.