CPT Code 96372: Having Problems Getting Approval?

Have you ever billed for a CPT injection code only to get hit by a denial or rejection without knowing why? Turns out, that’s actually a pretty common occurrence.

One of the top reasons for medical billing denials is the absence or misuse of modifiers on CPT code 96372, which can lead to a Denial Code 4 from insurers. To prevent this from happening, medical providers and coders must consistently report the correct codes while using a modifier that matches.

So what do you do? Here’s what your team needs to know to use this tricky code correctly:

What is CPT Code 96372?

The American Medical Association’s Current Procedural Terminology (CPT) code 96372 is a medical procedural code for “therapeutic, prophylactic, and diagnostic injections (excluding chemotherapy and other highly complex drug or biologic agent administration); subcutaneous or intramuscular.”

Criteria for Reimbursement:

96372 CPT code reimbursement is allowed when the injection is performed alone or with other procedures/services as permitted by the National Correct Coding Initiative (NCCI) procedure to procedure editing.

Separate reimbursement will not be allowed for CPT code 96372 when billed with an Evaluation and Management (E/M) Service (CPT code 99201-99499) by the same rendering provider on the same service date. If patient-supplied medication is being administered, the same medication, along with the dosage, must be entered on the CMS-1500 Box 19 or the equivalent loop and segment of the 837P.

What Are the Reasons for CPT Code 96372 Denials?

Here are the reasons that CPT code 96372 gets denied according to American Medical Association (AMA) Current Procedural Terminology (CPT) and Centers for Medicare and Medicaid Services (CMS) guidelines.

• CPT code 96372 is reported by the physician in a facility setting.
• CPT code 96372 is submitted together with an E/M service and with CMS Place of Service (codes) 19, 21, 22, 23, 24, 26, 51, 52, and 61 for the same patient by the same individual physician or other qualified healthcare professional on the same date of service. Only the E/M service will be reimbursed regardless of whether a modifier is reported with injection(s).
• Procedural code 96372 is performed by another healthcare provider other than the physician or other qualified health professionals without direct supervision for any or all purposes of patient assessment, provision of consent, safety oversight, and intra-service supervision of staff in a non-facility setting. To report this kind of circumstance, CPT code 99211 would be appropriate.
• The procedure code 96372 already includes a general assessment of the patient.
• If the need for the injection was already determined at the previous visit (billed as an E/M code), you cannot bill again for the same service. However, you can bill for the injection and an E/M code at the same visit if an additional E/M service is provided beside the injection. That E/M service would have to be appropriately documented.
• Inappropriate or missing modifier.
• CPT code 96372 is not properly documented, indicating that a procedure or service was distinct or independent from other services performed on the same day.
• CPT code 96372 is used for certain types of vaccinations. Most vaccinations are typically coded with 90471 or 90472. Medicare uses G0008 as the administration code for flu vaccinations.
• Procedure code 96372 is billed for injections related to the provision of chemotherapy services. The proper CPT code to use is 96401-96402.

What is Modifier 59?

Modifier 59 is used to identify procedures or services, other than E/M services, that are not usually reported together but are appropriate under the circumstances.

Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same provider.

However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only use modifier 59 if it best explains the circumstances, and no other descriptive modifier is available. For this reason, CPT modifier 59 is often the “modifier of last resort.” Modifier 59 should not be appended to an E/M service.

Inappropriate Use of Modifier 59

• Modifier 59 is used when it is not medically necessary.
• Modifier 59 is used to indicate that a procedure code was performed more than once per day. Instead, use anatomical modifiers to distinguish their repeat procedures. If those were not available, use modifier 76 (repeat service), as MAC directed.

When to Use CPT 96372 Appended With 59

When a patient receives two or three intramuscular or subcutaneous injections, CPT code 96372 should be reported for each injection performed (either IM or SubQ). Modifier 59, Distinct Procedural Service, would be appended to the second and any subsequent injection codes listed on the claim form. In other words, appending CPT modifier 59 indicates that the injection is a separate service.

Note that for professional reporting, code 96732 requires direct physician supervision. It is reported per injection, even if more than one substance or drug is in the single injection. Documentation in the patient’s medical record must support the use of this modifier.

Here’s an example: Let’s say a patient comes in with knee pain. The doctor diagnoses him with osteoarthritis and gives him an injection of Toradol. To code this scenario correctly, you would first list the symptoms for the office visit with a 25 modifier, followed by the substance administration for the condition. Then, you put a 59 modifier on the 96372. So, there would be three line items, which would look like:

• Knee pain 719.46 (ICD10 25.569) 99213 – 25
• Osteoarthritis 715.96 (ICD M17.9) J1885
• Osteoarthritis 715.96 (ICD10 M17.9) 96372 – 59

Solve Your Medical Coding Errors With DrCatalyst

Since medical billing and coding tasks can be quite demanding, running these operations in-house may not make economic or strategic sense. The medical industry changes quickly, which makes it challenging for medical practices to keep up with new rules and regulations.

Outsourcing your medical billing and coding is one of the best ways to make your billing process more efficient and increase patient satisfaction. DrCatalyst provides award-winning medical billing and coding services that ensure on-time and accurate billing for better revenue and higher profits. Our medical coding and billing meet the highest industry standards to eliminate delays or denials from insurance providers once and for all.

If your practice needs help with medical billing, contact us as soon as possible for a 1:1 consultation with one of our billing experts.