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What can be the possible reason for the rejection of your charge for a specific CPT injection code?

Considering this scenario: One charge for a specific CPT injection code was denied or rejected. That is a relatively regular event. Wouldn’t it be disappointing, especially if one didn’t know why it was turned down?

So, what’s next? The next step would undoubtedly be resubmitting the claim line with the correct qualifier for processing, but it is not essential to go through the reopening procedure.

Several reasons are there when we talk about denying our charge for the CPT injection code.

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Reimbursement Criteria for CPT Code 96372

When the injection is administered solely or in combination with additional procedures/services as authorized under the National Correct Coding Initiative (NCCI) procedure, the 96372 CPT code is reimbursed.

 

When invoiced in combination with an Evaluation and Management (E/M) Service (CPT code 99201-99499) by the same rendering provider on the same day of service, separate reimbursement will not be authorized. If a patient-supplied medicine is provided, the drug name and dosage must be recorded on the CMS-1500 Box 19 or the 837P’s comparable loop and segment.

CPT Code 96372 Identification

The American Medical Association’s Current Procedural Terminology (CPT®) code 96372 is a medical procedural code that falls within the Therapeutic, Prophylactic, and Diagnostic Injections and Infusions category. A therapeutic, prophylactic, or diagnostic material (a fluid, a medicine, etc.) is injected into the patient’s body via an intramuscular or subcutaneous route. Under the physician’s direct supervision, the process is carried out by the physician himself, his assistant, or a nurse. This code does not cover the injection of vaccination or toxoid.

Reasons for CPT code 96372 rejections

As per the American Medical Association’s (AMA) Current Procedural Terminology (CPT) and the Centers for Medicare and Medicaid Services (CMS) criteria, CPT code 96372 is rejected due to the following reasons:

  • CPT code 96372 is not correctly recorded, demonstrating that a treatment or service was different or separate from other services provided on the same day
  • Certain immunizations are coded with CPT number 96372. The most common vaccine codes are 90471 and 90472. The administrative code for flu vaccines in Medicare is G0008.
  • Injections related to chemotherapy services are billed under procedure code 96372. The correct CPT code is 96401-96402.
  • A broad assessment of the patient is already included in procedure code 96372.
  • The modifier is incorrect or absent.
  • You could not bill for the same service if the necessity for the injection were previously identified at a prior visit (billed as an E/M code). If an extra E/M service was delivered in addition to the injection, you could bill for both the injection and the E/M code on the same visit. That E/M service would need to be appropriately documented.
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When should CPT 96372 with modifier 59 be used?

CPT code 96372 should be entered for each injection given when patients receive two or three intramuscular or subcutaneous injections. Modifier 59, Distinct Procedural Service, would be append with the second admin code and any future admin codes on the claim form. In other words, adding CPT modifier 59 to an injection implies a distinct service.

Code 96732 necessitates direct physician supervision for professional reporting. Even if a single injection contains many substances or drugs, it is recorded per injection. The usage of this modification must be supported by documentation in the patient’s medical record.

Conclusion

  • When billing for specific procedures, the medical provider or coder must know which CPT codes to use.
  • In some circumstances, a modifier for the procedure code should be specified, and it should be consistent with the CPT code.
  • The insurer may issue Denial Code CO4 if the modifiers are incorrect or absent.
  • Invoice for specific operations with experience and knowledge of what codes to use. The modifier should be indicated if there is an issue, such as an incompatible CPT code or an unavailable injection facility.
  • When invoicing your medical provider(s), make sure that you are using appropriate procedure descriptions along with correct modifier markings on top-level billing documents like coding algorithm messages. These can help prevent rejection from insurers who may view them differently.