CPT 96367 Reimbursement & Benchmarks

CPT code 96367 represents an additional sequential intravenous infusion of a new substance or drug, up to one hour, performed in conjunction with a primary infusion procedure. This code is significant in clinical settings where patients require multiple medications or therapies administered intravenously during a single encounter. Nationally, the use of 96367 is relevant across a range of specialties, including internal medicine, interventional cardiology, and infusion therapy clinics.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Understanding payer coverage and billing requirements for 96367 is essential for providers and billing professionals to ensure accurate reimbursement and compliance.

Readers will gain insights into the clinical context of sequential intravenous infusions, current policy updates, and relevant benchmarks for this procedure. The publication also addresses common modifiers, associated taxonomies, and ICD-10 diagnoses linked to 96367, providing a comprehensive overview of its application in medical billing and coding. This summary serves as a resource for healthcare professionals seeking clarity on the procedural and administrative aspects of sequential IV infusions.

CPT Code Overview

CPT code 96367 is used to report an additional sequential intravenous infusion of a new substance or drug, lasting up to one hour. This code is listed separately in addition to the primary procedure and is applicable for therapeutic, prophylactic, or diagnostic infusions. The service type falls under Medicine Services and Procedures – Intravenous infusion for therapy, prophylaxis, or diagnosis. The typical site of service for this procedure is an infusion setting, where patients receive intravenous medications or treatments as part of their care.

Clinical Context

A patient presents to an infusion therapy clinic for intravenous treatment of a chronic condition, such as rheumatoid arthritis or an infectious disease. The patient receives a primary infusion of a therapeutic drug. During the same session, an additional sequential intravenous infusion of a new substance or drug is administered, lasting up to one hour. This sequential infusion is documented and coded separately from the primary infusion. The clinical workflow involves monitoring the patient for potential complications, such as fever or nausea, and ensuring proper documentation of each substance infused.

Coding Specifications

Modifiers:
- Modifier 59: Distinct Procedural Service. Used when the additional sequential infusion is separate and distinct from other services provided during the same encounter.
- Modifier XE: Separate Encounter. Applied when the infusion occurs during a separate patient encounter on the same day.
- Modifier XS: Separate Structure. Used when the infusion is administered in a different anatomical location or structure.
Provider Taxonomies:

Taxonomy Code	Specialty Name

Nationally, the mean rate for CPT code 96367 is highest among UnitedHealth Group at $51.89, while Medicare's mean rate is significantly lower at $30.95. The average commercial benchmark (BUCA) stands at $44.59, which is notably above the Medicare rate. Cigna and UnitedHealth Group both exceed the BUCA mean, indicating higher commercial reimbursement levels.

Rate dispersion, measured by the difference between the 75th and 25th percentiles, varies across payers. Medicare shows the tightest range at $3.00, reflecting minimal variation in rates. In contrast, UnitedHealth Group and Cigna exhibit the widest dispersions, with ranges of $27.25 and $26.83 respectively, suggesting greater variability in commercial payments. Aetna, Blue Cross Blue Shield, and BUCA display moderate dispersion.

The table and chart below present the full breakdown of national benchmarks for CPT code 96367 across major payers.

Related Diagnoses

Z51.81: Encounter for therapeutic drug level monitoring
- Relevant when the infusion is part of ongoing drug therapy requiring monitoring of drug levels.
T80.89XA: Other complications following infusion, transfusion and therapeutic injection, initial encounter
- Used if the patient experiences complications such as fever or nausea during or after the infusion.
Z79.899: Other long term (current) drug therapy
- Indicates the patient is receiving long-term drug therapy, which may necessitate sequential infusions.
R50.9: Fever, unspecified
- Documents the presence of fever, which may be a complication or reason for infusion therapy.
R11.2: Nausea with vomiting, unspecified
- Used if the patient experiences nausea and vomiting, either as a complication or as a symptom being treated by infusion.

Related CPT Codes

96366: Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure)
- Used when the infusion of a substance or drug continues beyond the initial hour. Commonly used together with 96367 if the sequential infusion exceeds one hour.
96368: Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure)
- Used when a second substance or drug is infused concurrently with another infusion. May be used as an alternative or in addition to 96367 depending on the clinical scenario.

These codes are often used in combination to accurately document complex infusion regimens involving multiple drugs or substances.

The table and chart below present the full breakdown of national benchmarks for CPT code 96367 across major payers.

`261QI0500X`	Infusion Therapy Clinic/Center
`207RI0011X`	Interventional Cardiology Physician
`207R00000X`	Internal Medicine Physician

OpenPayer

Summary & Overview

CPT 96367: Sequential Intravenous Infusion of New Substance, Up to 1 Hour