Pulmonology Coding Alert

Question: We recently received a denial of infusion code +96366 even though it was a multiple infusion and it lasted well over an hour. Could you please review the rules for reporting infusion codes?

Oregon Subscriber

Answer: When coding multiple-substance infusion claims, report the initial infusion with 96365 (Intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; initial, up to 1 hour). If the initial infusion lasts more than an hour, include +96366 (... each additional hour [List separately in addition to code for primary procedure]) for each additional infusion hour.

To rightfully report 96365-96366, the session must meet the following requirements:

• The pulmonologist must be administering the infusion for therapeutic, prophylactic or diagnostic purposes.

• The pulmonologist must supervise the entire session.

• The infusion must last for longer than 30 minutes.

• The infusion must not be an inherent component of another procedure, such as a CT scan.

• A healthcare professional must be in attendance during the entire session.

You likely were denied because payers will deny any +96366 claim for less than 30 minutes of additional infusion time beyond the first hour. For example, if a patient receives a 75-minute therapeutic infusion, you can report only 96365. You won't be able to account for the 15 minutes of infusion past the hour mark.

If the patient receives an infusion of a single drug that lasts one hour and 45 minutes, however, the physician would report 93635 for up to one hour and +96366 for the additional 45 minutes.