Summary & Overview
CPT 96380: RSV Monoclonal Antibody Intramuscular Prophylaxis with Counseling
CPT code 96380 represents the intramuscular administration of a monoclonal antibody to protect patients against respiratory syncytial virus (RSV), with counseling provided by a physician or other qualified healthcare professional. This seasonal prophylactic intervention is clinically significant for populations at elevated risk of severe RSV, influencing preventive care workflows in outpatient and ambulatory settings across the country. The code captures both the injection and associated counseling, clarifying billing for a bundled preventive service.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise national overview of coverage considerations and payer inclusion, clinical context for use in at-risk populations, and operational benchmarks relevant to ambulatory administration of seasonal monoclonal antibody prophylaxis. The content outlines common billing modifiers used with the service where applicable and highlights documentation elements tied to counseling and intramuscular administration.
This publication helps clinicians, billing staff, and policy professionals understand how CPT code 96380 is used in practice, what to expect in payer interactions, and where to look for policy updates affecting preventive monoclonal antibody services delivered in outpatient settings.
Billing Code Overview
CPT code 96380 describes administration of a monoclonal antibody product to protect the patient against respiratory syncytial virus (RSV). The service is a seasonal intramuscular injection given to provide passive immunity against RSV. A physician or other qualified healthcare professional also provides counseling related to the administration as part of the service.
Service type: Preventive monoclonal antibody administration with counseling
Typical site of service: Outpatient clinic, physician office, or ambulatory care setting.
Clinical & Coding Specifications
Clinical Context
A 4-month-old infant with prematurity and chronic lung disease presents during RSV season for prophylaxis with a monoclonal antibody. The infant is brought to an outpatient pediatric clinic or ambulatory infusion center by a caregiver. A physician or other qualified healthcare professional evaluates the infant, documents eligibility for prophylaxis, obtains informed consent, and counsels the caregiver about expected benefits, risks, and post-injection monitoring. The clinician prepares the intramuscular seasonal monoclonal antibody product, administers a single dose intramuscularly, observes the infant for a brief period for immediate adverse reactions, and documents the counseling and administration in the medical record. Billing uses 96380 for the provider-administered seasonal RSV monoclonal antibody dose. Typical sites of service are outpatient pediatric clinics, ambulatory infusion centers, or community health centers; administration is recorded during a scheduled prophylaxis visit and may occur alongside routine well-child care or respiratory disease follow-up visits.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure | Use when a distinct E/M is performed and documented in addition to the 96380 injection and counseling. |