Therapeutic, prophylactic, or diagnostic injection (subcutaneous or intramuscular)
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. Injection/infusion billed without drug supply code - incomplete claim
Very Common96372 (therapeutic/diagnostic injection admin) represents ONLY the administration service - NOT the drug itself. Must bill with drug supply code (J-code, HCPCS, or NDC) for complete service. Administration code alone will deny as incomplete. Total reimbursement typically $25-50 admin + drug cost.
Common Causes
- • Only administration code submitted - no J-code for drug product
- • Drug supply code denied - administration code denied as dependent
- • Billing system separated admin and drug codes onto different claims
Resolution Strategy
Submit corrected claim with both codes: 96372 (administration) + appropriate J-code (drug product). Example: 96372 + J1885 (ketorolac 15mg IM) for Toradol injection. Include drug name, dose, route (IM/SQ), administration site, and lot number. If using free samples, bill only 96372 (administration) and note 'drug provided as sample - no charge' in documentation.
2. Billed with E&M same day without significant, separately identifiable service
Very Common96372 bundled into E&M visit (99211-99215) when injection is only reason for visit OR minor component of visit. If E&M service is significant and separately identifiable beyond injection decision, both codes billable with modifier -25 on E&M. Without modifier or documentation of separate E&M, injection admin bundled - not separately paid.
Common Causes
- • Patient presents for flu shot only - 96372 billable, E&M not appropriate (use 99211 if minimal E&M required)
- • E&M billed same day as injection without modifier -25 - bundled together
- • Modifier -25 on E&M but documentation shows only 'patient requested B12 shot' - not significant separate service
Resolution Strategy
If separate E&M service provided (e.g., patient presents for injection but also has new problem addressed requiring history/exam/MDM separate from injection), add modifier -25 to E&M code and document: 'Patient presented for scheduled Depo-Provera injection. Separately, patient reported new onset lower back pain for 3 days. Performed focused exam of lumbar spine...' If E&M only for injection decision, drop E&M code and bill only 96372. If patient only received injection without separate problem addressed, 99211 not appropriate - bill 96372 only.
💬 Plain Language Explanation
What this means
This is an injection or immunization given by a healthcare provider. A medication or vaccine was injected into your muscle or under your skin.
Why you might see this
This is a very common code. You'll see it whenever you receive an injection, such as a flu shot, vaccine, or medication injection. Sometimes this is billed separately from the office visit, and sometimes it's included.
Common context
Very common code - appears on most bills with injections or immunizations. Sometimes bundled with office visits.
What to ask your provider
"'Was this injection billed separately, or was it included in my office visit? Some insurance plans bundle this into the visit charge.'"
Relative Value Units (RVUs)
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Clinical Information
When to Use
Subcutaneous or intramuscular injection of medication for therapeutic, diagnostic, or prophylactic purposes
Common Scenarios
Documentation Requirements
- Medication name, dose, route documented
- Indication for injection
- Patient consent if applicable
- Administration site documented
- Medication lot number and expiration (if vaccine)
Coding Guidelines
Common Modifiers
Bundling Rules
- Can bill with E/M visit using modifier 25 on E/M
- Medication billed separately with J-code
- Cannot bill multiple times for single injection
Exclusions
- Do not use for IV injections (use 96374)
- Do not use for intralesional injections (use 11900-11901)
- Do not use for preventive vaccines (use 90471-90474)
Coding Notes
Clinical scenarios
- Medication name, dose, route documented
- Indication for injection
- Patient consent if applicable
- Medication name, dose, route documented
- Indication for injection
- Patient consent if applicable
- Medication name, dose, route documented
- Indication for injection
- Patient consent if applicable
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Code Details
Medicare Pricing
PFSRVU Breakdown
OPPS Details
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Ask a QuestionFrequently Asked Questions
CPT 96372 is the billing code for "Therapeutic, prophylactic, or diagnostic injection (subcutaneous or intramuscular)". Subcutaneous or intramuscular injection of medication for therapeutic, diagnostic, or prophylactic purposes
Medicare pays approximately $13.91 for CPT 96372 (national average). Actual payment varies by geographic location due to GPCI adjustments. Hospital and commercial insurance rates are typically 2-4x higher than Medicare rates.
CPT 96372 has a total RVU of 0.68, broken down as: Work RVU 0.17, Practice Expense RVU 0.49, and Malpractice RVU 0.02. RVUs (Relative Value Units) determine Medicare reimbursement rates.
The most common denial reason for CPT 96372 is "Injection/infusion billed without drug supply code - incomplete claim". 96372 (therapeutic/diagnostic injection admin) represents ONLY the administration service - NOT the drug itself. Must bill with drug supply code (J-code, HCPCS, or NDC) for complete service. Administration code alone will deny as incomplete. Total reimbursement typically $25-50 admin + drug cost. Common causes include: Only administration code submitted - no J-code for drug product; Drug supply code denied - administration code denied as dependent. Appeal success rate is approximately 70-80%.
Key documentation requirements for CPT 96372 include: Medication name, dose, route documented; Indication for injection; Patient consent if applicable; Administration site documented. Missing or incomplete documentation is a leading cause of claim denials for this code.
Bundling considerations for CPT 96372: Can bill with E/M visit using modifier 25 on E/M. Medication billed separately with J-code Use an NCCI bundling checker to verify specific code combinations before billing.
Common modifiers for CPT 96372 include: 59 (When injection separate and distinct from other service). Modifiers indicate special circumstances and can affect reimbursement or prevent claim denials.
The typical time requirement for CPT 96372 is Typical: 5-10 minutes. Time-based codes require documentation of the actual time spent providing the service.