CPT Code 96372 Reimbursement

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Consider the following scenario: You charge for a specific CPT injection code, but you are denied or rejected. That is a relatively regular event. Wouldn’t you be disappointed, especially if you didn’t know why you were turned down?

When invoicing for specific operations, the medical provider or coder must be experienced enough to know which CPT codes to report. Furthermore, a modifier should be indicated for the procedure code in specific cases, and it should be compatible with the CPT code. Incorrect or missing modifiers might result in the insurer issuing Denial Code CO4; this is one of the most prevalent grounds for medical billing denials.

So, what are you going to do? The next step would be to resubmit the claim line with the correct qualifier for processing, but it is not essential to go through the reopening procedure.

Recognizing CPT Code 96372

The American Medical Association’s Current Procedural Terminology (CPT) code 96372 is a medical practice that falls into the category of Targeted therapy, Prophylactic, and Diagnostic Injections and Infusions (Excludes chemotherapy and other massively complicated drug or extremely complex pharmacologic agent management); highly efficacious or intramuscular.

CPT Code 96372 Reimbursement Criteria

When the injection is done alone or combined with other processes permitted by the National Correct Coding Initiative (NCCI) process to process modification, CPT code reimbursement is authorized.

When invoiced in combination with an Evaluation and Management (E/M) Service (CPT codes 99201-99499) by the same rendering source on the same day of operation, additional reimbursement for CPT code 96372 will not be permitted. If a physician’s medicine is provided, must note the drug name and dose on the CMS-1500 Box 19 or the comparable loop and section of the 837P.

Denials for CPT code 96372 include the following reasons:

The following are the reasons why CPT code 96372 is rejected under American Medical Association (AMA) Current Procedural Terminology (CPT) and Centers for Medicare and Medicaid Services (CMS) rules.

  • The physician reports CPT code 96372 in an institutional environment.
  • Procedural code 96372 is conducted in a non-facility set – up by some other medical professional, besides the physician or other competent healthcare providers, without close supervision for any of the reasons for health assessment, permission requirement, security supervision, and based on inter monitoring of employees. CPT number 99211 would be acceptable for reporting this type of situation.
  • A comprehensive evaluation of the client is already included in procedure code 96372.
  • You could not bill for the same treatment if the necessity for the injection were previously determined during the prior appointment (billed as an E/M code).
  • You are not permitted to charge for the same service twice. If given an extra E/M service parallel to the injection, you could trust both the injection and an E/M code at the same appointment. This E/M service would need to be adequately described.
  • CPT code 96372 is not correctly recorded, showing that a treatment or service was different or unique from other operations done on the same day.
  • CPT code 96372 is assigned to specific types of vaccines. The majority of vaccines are generally classified as 90471 or 90472. G0008 is the Medicare administrative code for flu vaccines.
  • Injections linked to the delivery of chemotherapy treatments are invoiced using procedure code 96372. The correct CPT code is 96401-96402.
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