CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPO26

Therapeutic, Prophylactic, Diagnostic, Injection and Infusion Administration Coding

Billing, coding, documentation, and reimbursement rules for injection and infusion services provided to Blue Cross and Blue Shield of New Mexico members; applies to providers submitting claims to the Plan.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyTherapeutic, Prophylactic, Diagnostic, Injection and Infusion Administration Coding

Policy CodePolicy CPCPO26

Change TypeClarification (non-material)

Effective Date

Next Review Date

Key ActionSubmit supporting documentation (orders, drug name/dosage, start/stop times, route, site, monitoring and signatures) when requested to determine eligible reimbursement.

SourceLink

POLICY UPDATE CHANGES

Clarification added above code tables; Additional Resources updated; References updated.

1.0policy version

09/19/2025committee approval

1 per dayinitial service limit

J2357+96372example code pairing

7 itemsrelated policies

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Coverage and Reimbursement Criteria

Bundling and excluded separate reimbursement

Reimbursement Information — bundled services and exclusions

ALL of the following

The Plan may request supporting documentation to determine eligible reimbursement. Submission of codes must be fully supported in the medical record.
Failure to adhere to coding and billing policies may impact claims processing and reimbursement.
Services that are mutually exclusive, integral to, incidental to, or within the global period of a primary service are not eligible for separate reimbursement.
Examples include routine supplies and equipment associated with injections/infusions.
Routine services, equipment, and supplies that are commonly furnished or are a usual part of the injection and/or infusion procedure (during an office visit or office procedure) are included in the general charge and are ineligible for separate reimbursement and should not be billed separately.
- Use of local anesthesia.
- IV start.
- Access to an indwelling IV, subcutaneous catheter, or port.
- Flush at conclusion of infusion.
- Standard tubing, syringes, and supplies.
- Supplies used during administration of injections or intravenous infusions are considered integral and not separately reimbursable.
Some HCPCS supply codes are not separately reimbursable when those supplies are utilized on the same date of service as an E/M service or procedure performed in a non-facility location or place of service; the Plan will not separately reimburse the HCPCS supply codes in that circumstance.

Reporting, Supervision, and Hierarchy

Reporting, supervision, and hierarchy — service reporting rules and supervision requirements

ALL of the following

Hydration codes (96360-96361) report IV hydration infusions (pre-packaged fluids and/or electrolytes) and are not used to report infusion of drugs or other substances. A minimum time of 31 minutes is required to report hydration per CPT guidance.
Therapeutic, prophylactic, and diagnostic injections and infusions (CPT 96365-96377, 96379) are for administration of substances/drugs. Fluids used solely to administer drugs are incidental and not separately reimbursed.
Chemotherapy and other highly complex drug or biologic administrations (per CPT definitions) require direct supervision and advanced staff competency due to higher risk of severe adverse reactions; these services generally require physician or qualified health care professional oversight for assessment, consent, safety, and intra-service supervision.

Modifiers, Waste Reporting, and Self‑Supplied Drugs

Modifiers, waste reporting, and coding guidance

ALL of the following

Modifier -25: If a significant, separately identifiable office or other outpatient E/M service is performed on the same date as an injection/infusion administration, the E/M may be reported separately with modifier -25. Documentation may be required to allow separate reimbursement. Hospitals should append -25 only if significant, separately identifiable E/M services are performed in the same encounter with drug administration services.
Modifier -59: Use when necessary to indicate a procedure or service was distinct or independent from other services performed on the same date (different session, procedure, site/organ system, incision, lesion, or injury). If another established modifier applies, it should be used instead of -59. Documentation must support use of -59.
Example: Multiple intramuscular or subcutaneous injections — submit CPT 96372 for each injection and append modifier -59 to the second and subsequent injection codes; medical record must support modifier use.
Modifiers JW and JZ for drug waste reporting: HCPCS level II codes should reflect the drug and dosage administered. The JW modifier is appended to report discarded/wasted drug amounts (billed on a separate line) in non-inpatient places of service; the JZ modifier indicates zero discarded amount. Documentation must identify dosage and reason for waste. Providers are encouraged to minimize waste.

Coverage Criteria — Member‑Supplied Drugs and Administration

Billing and coding expectations for administration and member‑supplied drugs

ALL of the following

If no E/M service is provided and a member supplies their own drug for administration to a provider, and the drug is administered under direct supervision, providers should report the appropriate CPT administration code.
When a member‑supplied drug is administered and no E/M is reported, providers should include a separate line for the drug code and dosage with a zero-dollar ($0.00) charge, as applicable, to document the drug supplied by the member.
Providers should select codes that accurately describe the administered drug(s), services, or procedures. If no appropriate code exists, report the service using the appropriate unlisted code and include a description and supporting documentation.

CPT/HCPCS Codes, Modifiers, and Coding Rules

Injection/Infusion CPT codesCPTCovered

96360-96361	Hydration IV infusion initial and add-on
96365-96377, 96379	Therapeutic, prophylactic, diagnostic injections and infusions (administration of substances/drugs)
96372	Therapeutic, prophylactic, or diagnostic injection (SC/IM)
96376	Sequential IV push of same drug (facility-only reporting noted)

HCPCS/drug modifiersHCPCSCovered

JW	Drug amount discarded
JZ	No drug amount discarded
J2357	Example HCPCS code for therapeutic injection (illustrative)

example injection/administration codes and modifiersmixedCovered

J2357	Example HCPCS drug code (as given in document)
96372	Therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular
JW	Modifier for discarded/not administered amount of drug
JZ	Modifier indicating zero drug amount discarded/not administered

Hydration: reporting thresholds

Hydration minimum timeMinimum 31 minutes of hydration infusion required to report hydration codes (CPT 96360-96361).

Hydration code scopeHydration codes (96360-96361) report IV fluids/electrolytes only and are not used for drug infusions or when fluids are incidental to drug administration.

Supervision requirementHydration IV infusions usually require direct supervision for consent, safety oversight, or intra-service supervision of staff.

Initial service per encounter

Initial service reporting limitOnly one initial infusion/injection service code may be reported per member encounter per day for physician/QHP and facilities, unless protocol or the member's condition requires two separate IV sites.

Documentation, Billing, and Provider Responsibilities

Documentation Required

Documentation requests for claim review

The Plan may request supporting documentation during claim review to determine eligible reimbursement. Documentation should include orders, drug name and dosage, administration details, infusion start/stop times and rates, route and anatomic location, signatures or attestations, preparation and monitoring notes, member reactions and post-procedure instructions. Services considered mutually exclusive, integral, incidental, or within a global period are not eligible for separate reimbursement; submission of codes must be supported by the medical record.

Orders from physician or non‑physician provider (NP/PA)
Type of infusion(s) and route of administration (intradermal, intramuscular, intravenous, subcutaneous)
Drug name, dosage, and preparation details
Start and stop times, and rate of each infusion
Signatures or signature attestations for all personnel
Documentation of anatomic location and site preparation
Member reactions and monitoring (vital signs, times of interactions)
All post‑procedure instructions related to the injection

Definitions

Injection (definition)

DefinitionInjection: introduction of a substance into the body using a syringe and attached needle via subcutaneous, intravenous, intramuscular, or intrathecal routes.

Common routesSubcutaneous (SC), Intravenous (IV), Intramuscular (IM), Intrathecal (spinal).

PurposeUsed for therapeutic, prophylactic, or diagnostic administration of substances using needle/syringe delivery.

Infusion and IV push (definition)

DefinitionInfusion: intravenous or subcutaneous administration of therapeutic solutions (drip); includes initial, concurrent, and sequential infusions and IV push (an injection or infusion of 15 minutes or less).

Initial vs concurrent vs sequential

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyTherapeutic, Prophylactic, Diagnostic, Injection and Infusion Administration Coding

Policy CodePolicy CPCPO26

Change TypeClarification (non-material)

Effective Date

Next Review Date

Key ActionSubmit supporting documentation (orders, drug name/dosage, start/stop times, route, site, monitoring and signatures) when requested to determine eligible reimbursement.

SourceLink

On This Page

For physician or other QHP reporting, the initial infusion service is reported as the primary reason for the encounter.

For facility reporting, utilize the established hierarchy: chemotherapy services are primary to therapeutic/prophylactic/diagnostic services, which are primary to hydration; infusions are primary to pushes, which are primary to injections.

Only one initial service code may be reported per member encounter per day by physician/QHPs and facilities, unless protocol or the member’s condition requires two separate IV sites; the second initial service may be reported with an appropriate modifier to reflect additional time/effort.

If the member returns for a separate encounter on the same day requiring infusion or injection, another initial code may be billed with modifier -59 for that service; documentation must support separate encounter or distinct service.

Sequential infusions (administration of a different drug/service through the same IV site after completion of the first infusion) may be billed when documented justification supports sequential rather than concurrent infusion; sequential infusions may be billed only once per sequential infusion of the same fluid mix.

The administration time of an infusion/injection is a separate service from an E/M; time spent on an injection/infusion should not be factored into total time for selecting an E/M level of service.

Example: Report HCPCS drug code (e.g., J2357) with the appropriate administration CPT (e.g., 96372) and append JW for discarded amount or JZ if none was discarded.

Second IV site exceptionIf two separate IV sites are required, the additional initial service may be reported and the difference in time and effort may be indicated by appending an appropriate modifier.

Separate visit allowanceIf the member returns for a separate encounter on the same day, another initial infusion or injection code may be billed with modifier -59 for that service.

Member‑supplied drug billing

Zero-dollar drug line when member-suppliedWhen a member supplies their own drug and no EIM service is provided, include a separate line for the drug code and dosage with a $0.00 charge.

Administration reportingIf a member-supplied drug is administered under direct supervision, providers should report the appropriate CPT administration code (e.g., 96372).

Documentation for unlisted codesIf no specific code exists for the drug/service, report using an appropriate unlisted code with description/supporting documentation per Plan guidance.

Billing Rule

Example coding and modifier use for injected drugs

Report the HCPCS/HCPC and CPT codes that accurately describe the drug and the administration. Example: report HCPCS code J2357 with CPT code 96372 for therapeutic, prophylactic, or diagnostic injection by subcutaneous or intramuscular route. Append modifier JW when a portion of the drug was discarded (waste) or modifier JZ when no drug was discarded. When an unlisted code is used because no specific code exists, submit a full description and supporting documentation.

Report J2357 (HCPCS) with 96372 (CPT) for injected drug administration where applicable
Append modifier JW for discarded amount or JZ if zero discarded amount
Select codes that accurately describe the administered drug(s) and services
When using an unlisted code, include a description and supporting documentation

Billing Rule

Billing when member‑supplied drug is administered

When a member supplies their own drug and no EIM (external infusion management) service is provided, providers should report the appropriate CPT administration code (for example, 96372) for the injection/administration. Include a separate line reporting the drug product and dosage with a $0.00 charge to indicate member‑supplied medication, and ensure documentation demonstrates direct supervision and that no EIM service was performed.

If member‑supplied drug is administered and no EIM service is provided, report the appropriate CPT administration code (e.g., 96372)
Include a separate line for the drug product and dosage with a zero-dollar ($0.00) charge to denote member‑supplied medication
Ensure documentation supports direct supervision and that no EIM service was performed

Initial infusion is the primary reason for the encounter; concurrent infusion is a new substance infused at the same time and reported once; sequential infusion follows a primary service and requires a new substance (facilities may report CPT 96376 for sequential IV push of same drug).

IV pushDefined as an injection where administrator is continuously present to administer and observe the member, or an infusion of 15 minutes or less.

Qualified Health Care Professional (definition)

DefinitionQualified Health Care Professional: an individual qualified by education, training, licensure/regulation (when applicable) and facility privileging (when applicable) who performs and independently reports professional services within their scope of practice.

Scope and reportingQHPs report professional services consistent with their licensure and facility privileging; supervision requirements may apply for certain infusion services.

ExamplesIncludes physicians and other licensed clinicians authorized to perform and report injection/infusion services within their scope.

EIM service (definition and billing guidance)

EIM service contextIf no EIM service is provided and a member supplies their own drug which is administered under direct supervision, providers should report the appropriate CPT administration code and include a separate drug line with $0.00 charge.

Code selectionProviders should select codes that accurately describe administered drugs, services, or procedures; use an unlisted code only if no specific code exists and include supporting documentation.

Modifier/waste guidanceWhen reporting HCPCS drug codes, append JW for discarded/not administered drug amount or JZ if zero drug amount discarded/not administered.