Oncology & Hematology Coding Alert

Question: What is the guidance for billing injections when one dose is split into two syringes and administered in two legs? Would it be OK to bill 96372 with a 59 modifier as this is a separate site, or is it deemed as one injection because it is the same drug?

Codify Member

Answer: You may find different responses regarding whether to report 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) once or twice. Regardless of your practice’s final decision, you should be sure documentation supports two injections and describes the reason (medical necessity) for splitting a single dose into two injections.

Option 1: Some experts suggest you should report a single unit for administration of the same drug at two separate sites immediately sequential to one another. Keep in mind that by using the therapeutic administration code, the provider is paid for the pre- and post-injection work and the supplies associated with the injections as listed in CPT^®. The additional cost for the syringe and nursing work to inject a second time at a new site may not be seen to justify a second administration code. This logic is documented in a 2008 provider bulletin from First Coast Service Options Inc. (FCSO) where a chemotherapy administration code is used as an example (page 44, http://medicare.fcso.com/Publications_B/2008/138218.pdf).

Option 2: Other experts advise reporting 96372 and 96372-59 (Distinct procedural service) for split-dose injection administration. The reasoning is that the split dose is drawn up into two separate syringes and administered in two different anatomic sites. As support, many point to CPT^® Assistant (May 2010), which states that 96372 “should be reported for each intramuscular (IM) injection performed. Therefore, if two or three injections are performed, it would be appropriate to separately report code 96372 for each injection. Modifier 59, Distinct Procedural Service, would be appended to the second and any subsequent injection codes listed on the claim form.” The article, however, does not consider whether the IM injection is of the same drug or whether that affects reporting the quantity of the IM injections.

The provider should document the two injections and the reason for dividing the dose. Reasons may include preventing discomfort or toxicity caused by injecting the full dose at a single site, or the drug may be too thick or the quantity too large to be administered at a single site. Additionally, you may want to query the specific payer to determine if it has provided guidance or FAQs for such situations so you can better adhere to the payer’s billing expectations.