Medical billing is a complex process that requires a high level of expertise and knowledge. One common problem that medical providers face when billing for certain procedures is getting denied or rejected. This can be frustrating, especially if they don’t know why they got rejected. Inappropriate or missing modifiers can result in receiving Denial Code (CO) 4 from the insurer. This paper discusses the importance of appropriate modifier usage and provides an understanding of CPT code 96372.
Modifiers are two-digit codes added to CPT codes to indicate that a service or procedure has been altered in some way, but still falls under the main category of the original code. Inappropriate or missing modifiers can cause claims to be denied or rejected. It is essential for medical providers and coders to use the appropriate modifiers to ensure claims are processed correctly.
Denial Code (CO) 4 is one of the most common reasons for medical billing denials. It indicates that the procedure code submitted was not consistent with the modifier code submitted or was missing a modifier code altogether. This could be due to various reasons, such as not being aware of the appropriate modifier code to use, using an incorrect modifier code, or not using a modifier code at all. If a medical provider or coder receives a denial or rejection, the next step is to resubmit the claim line with the correct modifier code for processing. However, it is not necessary to go through the reopening process. The corrected claim can be submitted as a new claim line.
Exploring the CPT Code 96372
CPT Code 96372 is a medical procedural code that falls under the range of therapeutic, prophylactic, and diagnostic injections and infusions (excludes chemotherapy and other highly complex drug or highly complex biologic agent administration); subcutaneous or intramuscular. This code is used to report the administration of intramuscular or subcutaneous injections, such as vaccines or medications.
Navigating CPT Code 96372: When Can You Receive Reimbursement?
Prophylactic, and Diagnostic Injections and Infusions, excluding chemotherapy and other highly complex drug or biologic agent administration. The American Medical Association (AMA) maintains this code, and it is used for reporting subcutaneous or intramuscular injections.
The reimbursement criteria for CPT code 96372 state that reimbursement is allowed when the injection is performed alone or in conjunction with other procedures/services as allowed by the National Correct Coding Initiative (NCCI) procedure to procedure editing. However, separate reimbursement will not be allowed for CPT code 96372 when billed in conjunction with an Evaluation and Management (E/M) Service (CPT code 99201-99499) by the same rendering provider on the same date of service.
If a patient-supplied medication is being administered, the name of the medication and the dosage must be entered on the CMS-1500 Box 19 or the equivalent loop and segment of the 837P. Failure to comply with these guidelines may result in claim denials.
9 Reasons for CPT code 96372 Denials
- Claim denials can be frustrating for medical providers and coders, especially when the reason for the denial is not clear. Here are some of the reasons that CPT code 96372 may get denied, according to AMA and Centres for Medicare and Medicaid Services (CMS) guidelines:
- Reporting CPT Code 96372 in a Facility Setting
- CPT code 96372 is reported by the physician in a facility setting. In such a scenario, the reimbursement may get denied if the proper place of service code is not used or if the procedure is not covered under the patient’s health plan.
- Reporting CPT Code 96372 with E/M Service
- CPT code 96372 is submitted together with an E/M service and with CMS Place of Service (codes) 19, 21, 22, 23, 24, 26, 51, 52, and 61 for the same patient by the same individual physician or other qualified healthcare professional on the same date of service.
- Only the E/M service will be reimbursed regardless of whether a modifier is reported with injection(s). Therefore, it is essential to report the services accurately to ensure proper reimbursement.
- Procedural Code 96372 is performed by Another Healthcare Provider without Direct Supervision
- Procedural code 96372 is performed by another healthcare provider, other than the physician or other qualified health professionals, without direct supervision for any or all purposes of patient assessment, provision of consent, safety oversight, and intra-service supervision of staff in a non-facility setting. In such cases, CPT code 99211 would be appropriate to report the injection.
- Injections given as part of chemotherapy services should be billed using CPT codes 96401-96402, rather than procedure code 96372.
Inappropriate or Missing Modifier
Inappropriate or missing modifiers can also result in CPT code 96372 denials. Modifiers provide additional information about the services provided and help distinguish between services that are distinct or independent from other services performed on the same day. Therefore, it is crucial to use the correct modifier for each service provided.
The Solution to Approval Issues for CPT Code 96372:
Modifier 59 is an important tool for medical coders and billers, allowing them to identify procedures or services that are not normally reported together but are appropriate under certain circumstances. However, improper use of this modifier can lead to claim denials, delays in reimbursement, and potential legal issues. In this article, we will discuss the proper use of Modifier 59, as well as situations in which it should not be used. Modifier 59 is a Current Procedural Terminology (CPT) code modifier that is used to identify procedures or services that are not typically reported together but are appropriate under certain circumstances. It is used to indicate that a procedure or service is distinct or independent from other services performed on the same day by the same provider.
Using Modifier 59 for Multiple Injections of CPT Code 96372
According to the Centers for Medicare and Medicaid Services (CMS), Modifier 59 should only be used when no other descriptive modifier is available and the use of modifier 59 best explains the circumstances. This means that other modifiers, such as anatomical modifiers, should be used first to distinguish between repeat procedures, rather than relying on modifier 59. Additionally, Modifier 59 should not be appended to an Evaluation and Management (E/M) service.
Inappropriate Use of Modifier 59
- Improper use of Modifier 59 can lead to claim denials, delays in reimbursement, and potential legal issues. Some common examples of inappropriate use include:
- Using Modifier 59 when it is not medically necessary.
- Using Modifier 59 to indicate that a procedure code was performed more than once per day. Instead, anatomical modifiers should be used to distinguish between repeat procedures.
- Appending Modifier 59 to bundled procedures that are performed through the same incision. Some codes cannot be unbundled, even with the use of Modifier 59.
Example of Proper Use of Modifier 59
Let’s consider an example of when to use Modifier 59. A patient comes in with knee pain, and the doctor diagnoses them with osteoarthritis and decides to give them an injection of Toradol. The medical coder should report the knee pain as an office visit with a 25 modifier and the substance and administration with the condition. The medical coder should then append the 59 modifier to the 96372 code for the second and any subsequent injection codes listed on the claim form. This indicates that the injection is a separate service.
It is important to note that for professional reporting, code 96732 requires direct physician supervision. It should be reported per injection, even if more than one substance or drug is in the single injection. Documentation in the patient’s medical record must support the use of this modifier.
Modifier 59 is a useful tool for medical coders and billers to identify procedures or services that are not normally reported together but are appropriate under certain circumstances. However, it is essential to use the modifier correctly and only when it is medically necessary. Proper documentation must support the use of this modifier, and it should not be used as a substitute for other descriptive modifiers. By understanding the proper use of Modifier 59, medical practices can avoid claim denials, delays in reimbursement, and potential legal issues.
FAQs – The Whole Guide to CPT Code 96372
How do you bill a procedure code 96372?
Procedure code 96372 should be billed for each injection performed on a patient. It is important to use modifier 59 when the injection is a separate service from other treatments. Also, direct physician supervision is required, which means the injection must be done under the direct supervision of an MD.
Can you bill 96372 without a drug code?
No, in order to consider reimbursement for 96372-96379, an allowable drug or substance service code must be filed on the same claim. Even if the administered drug or substance was not supplied by the professional provider, the drug or substance being administered should still be filed on the claim with a $0.01 charge.
What is the difference between CPT code 90471 and 96372?
CPT code 90471 should be used for vaccines, while 96372 is for drugs. When billing 96372, it is important to use a 59 modifier on the drug or it may not be paid.
Properly understanding procedure code 96372 and its requirements for billing and reimbursement can ensure accurate and timely payments for medical services provided. Remember to use modifier 59 when appropriate and always file an allowable drug or substance service code on the same claim.