Pain Management Coding Alert

Question: Notes indicate that the physician provided 55 minutes of intravenous (IV) infusion treatment for a patient. I reported 96365 and received a denial. What did I do wrong?

Illinois Subscriber

Answer: It seems as if you might have used the wrong IV infusion code. For coding purposes, there are two types of IV infusion coding: hydration and therapy/prophylaxis/diagnosis. Check out this guidance on IV infusion coding, and then apply that knowledge when you resubmit the claim:

Hydration IV: When the provider performs hydration IV infusion, you’ll report 96360 (Intravenous infusion, hydration; initial, 31 minutes to 1 hour) for the first hour. For any subsequent hours of hydration IV infusion, report +96361 (…  each additional hour (List separately in addition to code for primary procedure)).

Therapy/prophylaxis/diagnosis IV: When the provider performs IV infusion for therapy, prophylaxis, or diagnosis purposes, you’ll report 96365 (Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour) for the first hour and the first drug the provider infuses. For any additional hours of therapy/prophylaxis/diagnosis IV infusion of the first drug, report +96366 (… each additional hour (List separately in addition to code for primary procedure)).

When the therapy/prophylaxis/diagnosis IV infusion involves multiple drugs or multiple infusions, round out your claim with these codes, depending on encounter specifics:

• +96367 — … additional sequential infusion of a new drug/substance, up to 1 hour (List separately in addition to code for primary procedure)
• +96368— … concurrent infusion (List separately in addition to code for primary procedure).

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