CurrentUnitedHealthcarePolicy 2025R0009B

Reimbursement for injection and infusion services (CMS-1500)

Governs UnitedHealthcare reimbursement when injection/infusion CPT codes (96360-96379) and related E/M services, HCPCS supplies, and drug codes are reported on the CMS-1500 form; applies to Commercial and Individual Exchange products and providers filing CMS-1500 claims (with limited state exception).

Policy Summary

PayerUnitedHealthcare

PolicyReimbursement for injection and infusion services (CMS-1500)

Policy CodePolicy 2025R0009B

Change TypeAdministrative/template and application updates

Effective Date

Next Review Date

Key ActionDo not separately bill injection CPTs 96372-96379 in listed facility places of service; in non-facility POS bill the injection as primary unless a significant, separately identifiable E/M (not CPT 99211) is reported with Modifier 25.

SourceLink

POLICY UPDATE CHANGES

Transferred content to shared policy template that applies to both UnitedHealthcare Commercial and Individual Exchange benefit plans.

Updated Application section to indicate this Reimbursement Policy applies to all UnitedHealthcare Commercial benefit plans.

96360-96379CPT codes addressed (Injection/Infusion)

All states except MSIndividual Exchange applicability

19,21,22,23,24,26,51,52,61Facility POS where injections not reimbursed

99211

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Coverage Criteria

Coverage criteria for injections, E/M, supplies, and drugs

Covered when the following rules are met for injections/infusions (CPT 96360-96379), associated E/M services, HCPCS supplies, and HCPCS drug codes billed on the same date by the same individual.

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title

Coding and Reimbursement Codes

Injection/Infusion CPT CodesCPTCovered

96360-96379	Injection and infusion services (therapeutic and diagnostic)
96372-96379	Therapeutic and diagnostic injection procedures referenced with E/M guidance

HCPCS Drug and Supply CodesHCPCSCovered

HCPCS (drug and supply codes)

HCPCS drug codes reimbursed separately; standard tubing/syringes/supplies considered inclusive

Separate E/M reimbursement requirement

RequirementE/M is reimbursed separately only when the E/M is significant, separately identifiable and Modifier 25 is appended

ExclusionCPT 99211 will not be reimbursed when submitted with an injection code, with or without Modifier 25

Preventive medicine exceptionPreventive Medicine E/M codes (CPT 99381-99412, 99429) do not require Modifier 25 and may be reported with injections

Non-facility implicationIn non-facility POS, E/M is presumed inherent to the injection unless Modifier 25 documents a significant separate E/M

Provider Billing and Documentation Actions

Billing Rule

Billing and modifier guidance for injections and E/M

Do not separately bill CPT codes 96372-96379 when the injection is performed by the same individual in a facility place of service (POS 19, 21, 22, 23, 24, 26, 51, 52, 61); only the E/M is reimbursed and the injection is not separately payable regardless of modifiers. In non-facility settings the injection is primary and the E/M is not separately reimbursed unless a significant, separately identifiable E/M unrelated to the injection is performed and Modifier 25 is appended (CPT 99211 is never separately reimbursed).

Facility POS (19,21,22,23,24,26,51,52,61): only E/M reimbursed; injection not separately reimbursed regardless of modifier. [[Supported by chunk 6]]
Non-facility POS: injection reimbursed; E/M not separately reimbursed unless significant, separately identifiable and Modifier 25 appended. [[Supported by chunk 7]]
CPT 99211 will not be reimbursed when submitted with an injection code, with or without Modifier 25. [[Supported by chunk 8]]

Definitions

Same individual (Federal Tax ID)

DefinitionSame Individual Physician or Other Qualified Health Care Professional = the same individual rendering health care services reporting the same Federal Tax Identification number

Use in policyDetermines when services billed on the same date by the same provider are considered together for reimbursement rules

Applies toPhysicians and other qualified health care professionals submitting CMS-1500 claims under one Federal Tax ID

Infusion

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

ScopeIncludes therapeutic and diagnostic infusion services when billed with E/M and HCPCS codes