ED Coding and Reimbursement Alert

Question: Progress notes indicate that my ED provider performed an intravenous (IV) infusion for therapy. The infusion lasted an hour and 46 minutes and involved a single substance. I reported 96365 x 2 on the facility claim, but the payer denied the claim. What went wrong?

Michigan Subscriber

Answer: You should have used a different code to represent the second block of infusion time. Your code choice for the first hour was correct.

On resubmission, report 96365 (Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour) for the first hour and +96366 (… each additional hour (List separately in addition to code for primary procedure)) for the remaining 46 minutes of infusion time.

Remember: Per CPT^®, you should use +96366 for additional time beyond the first hour of infusion for the same substance. If the provider introduces a new drug after the initial infusion, report +96367 (… additional sequential infusion of a new drug/ substance, up to 1 hour (List separately in addition to code for primary procedure)) instead. If the provider performed a different infusion at the same time as the first infusion, report +96368 (… concurrent infusion (List separately in addition to code for primary procedure)).

And no matter whether you use +96366, +96367, or +96368, remember that they’re add-on codes. You’ll need to report them as secondary to a base code — in this case, 96365.