CurrentColorado Rocky Mountain Health PlansPolicy N/A

Reimbursement for injections, infusions, and related E/M services on CMS 1500

Governs reimbursement of therapeutic/diagnostic injections (CPT 96372-96379), infusions (CPT 96365-96371), and hydration (CPT 96360-96361) billed on CMS 1500 and how those procedure codes interact with evaluation & management (E/M) codes across places of service for network physicians and qualified providers.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyReimbursement for injections, infusions, and related E/M services on CMS 1500

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateFeb 1, 2026

Next Review DateN/A

Key ActionSubmit accurate claims on the CMS 1500 form and monitor CMS/local carrier updates for policy or coding changes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CMS 1500Form applicability

96360-96379Primary procedure range

POS 19,21,22,23,24,26,51,52,61Non-separate POS

99381-99429Preventive E/M allowed

Reimbursement rules for injections, infusions, and associated E/M services

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Reimbursement criteria for injections/infusions and E/M

Covered when the following place-of-service and service‑separability rules are met:

When an E/M service and an injection or infusion (CPT 96360-96379) are submitted for the same patient, by the same individual physician or other qualified health care professional, on the same date of service in facility settings (POS 19, 21, 22, 23, 24, 26, 51, 52, 61), only the E/M is reimbursed; the injection/infusion is not separately reimbursed regardless of modifiers.

In non‑facility settings (POS other than 19, 21, 22, 23, 24, 26, 51, 52, 61), when an injection/infusion and an E/M are provided by the same individual on the same date, only the injection/infusion is reimbursed unless a significant, separately identifiable E/M is performed and reported with Modifier 25.

CPT 99211 will not be reimbursed when submitted with a diagnostic or therapeutic injection/infusion (CPT 96372-96379), with or without Modifier 25.

Preventive medicine E/M codes (CPT 99381-99412, 99429) may be reported with an injection/infusion and will be reimbursed separately without requiring Modifier 25 because the preventive E/M components are not included in the injection procedure.

If a HCPCS drug code is billed in addition to an injection/infusion (CPT 96360-96379) in a non‑facility setting and no other service is performed the same day, both the HCPCS drug code and the injection/infusion code may be reimbursed.

When the same physician performs the injection in one place of service (non‑facility) and an E/M in a different place of service on the same date, both may be reimbursed provided the injection was performed in a POS other than the listed facility POS codes.

Relevant CPT codes and modifier guidance

Injection/Infusion CPT codesCPTCovered

96360-96361	IV hydration infusions
96365-96371	Infusion services
96372-96379	Therapeutic and diagnostic injections

E/M interaction codesCPT

99211	Office/outpatient visit, established patient - will not be reimbursed when submitted with injection
99381-99412, 99429	Preventive medicine codes - reimbursed with injections without Modifier 25

Modifier 25 requirement (inv-04)

RequirementModifier 25 must be appended to the E/M to report it separately with an injection/infusion in non‑facility settings when the E/M is a significant, separately identifiable service

Exceptions - CPT 99211CPT 99211 will not be reimbursed when submitted with a diagnostic or therapeutic injection code, with or without Modifier 25

Exceptions - Preventive MedicinePreventive medicine E/M codes (CPT 99381-99412, 99429) do not require Modifier 25 to be reported separately with injections/infusions

When requiredModifier 25 applies in non‑facility POS when E/M is unrelated to routine physician work inherent to the injection (e.g., beyond injection preparation, consent, safety oversight, intra‑service supervision)

Facility POS ruleIn facility settings (POS 19, 21, 22, 23, 24, 26, 51, 52, 61) injections/infusions are not separately reimbursed from the E/M, so Modifier 25 does not enable separate payment

Claims submission, documentation, and provider responsibilities

Documentation Required

Claims submission and policy updates

Submit claims using the CMS 1500 (or electronic equivalent) and monitor policy/coding updates; UnitedHealthcare Medicare Advantage may modify this reimbursement policy at any time to comply with CMS and national coding guidance.

Use the 1500 Health Insurance Claim Form (CMS 1500) or its electronic equivalent for all applicable services.
Regularly monitor CMS and local carrier updates; UnitedHealthcare may publish a new policy version to reflect CMS or national coding guideline changes.

Key definitions used in this policy

Hydration (inv-06)

DefinitionHydration: an IV infusion that consists of pre-packaged fluid and electrolytes strictly to replace fluids.

Relevant CPT rangeHydration services are reported within the CPT 96360-96361 hydration/infusion codes.

ContextTreated as an infusion procedure for reimbursement purposes and follows the same POS and E/M interaction rules as other infusion services.

Infusion (inv-07)

DefinitionInfusion: a controlled method of administering a substance (drugs, fluids, nutrients, etc.) continuously over an extended period of time.

CPT codesInfusion services are reported with CPT codes 96365-96371.

Reimbursement noteWhen performed in facility POS listed in the policy, infusion services are not separately reimbursed from the E/M; in non-facility settings Modifier 25 may allow separate E/M payment if criteria met.

Injection (inv-08)

DefinitionInjection: insertion of a drug, substance, or solution into a body part (e.g., subcutaneous tissue, muscle, vascular tree, or an organ).

CPT codesTherapeutic and diagnostic injections are reported with CPT codes 96372-96379.

Reimbursement noteIn non‑facility POS, injections are generally considered to include the E/M work inherent to the procedure; a significant, separately identifiable E/M may be separately reimbursed only with Modifier 25 (except as noted).

Same Individual Physician or Other Qualified Health Care Professional (inv-09)

DefinitionSame Individual Physician or Other Qualified Health Care Professional: the same individual rendering health care services reporting the same National Provider Identifier (NPI) number.

Billing implicationE/M and injection/infusion reported by the same individual (same NPI) on the same date are presumed to be part of the procedure unless the E/M is identified as significant and separately identifiable.

POS considerationWhen services are performed by the same individual in facility POS (19,21,22,23,24,26,51,52,61), injection/infusion is not separately reimbursed from the E/M.