CurrentUnitedHealthcarePolicy N/A

Reimbursement for injection and infusion services

Governs UnitedHealthcare Community Plan Medicaid reimbursement for therapeutic and diagnostic injection and infusion services (CPT 96360-96379 and 96372-96379), associated HCPCS supplies and drug codes, and related E/M coding when billed on CMS-1500 or UB04 as specified. Affects network and non‑network physicians and other qualified health care professionals providing services to Community Plan Medicaid enrollees.

Policy Summary

PayerUnitedHealthcare

PolicyReimbursement for injection and infusion services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDo not bill separate injection reimbursement in facility POS 19,21,22,23,24,26,51,52,61; in non‑facility bill injection codes and only bill E/M separately when a significant, separately identifiable E/M is documented (use Modifier 25, except CPT 99211).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

96372-96379Primary injection procedure codes referenced

96360-96379Injection/infusion code range

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

99211E/M code excluded

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Injection and E/M Reimbursement Criteria

Injection and E/M reimbursement criteria

Covered when the following conditions are met:

Facility place of service rule: When an E/M service and a therapeutic or diagnostic injection (CPT 96372-96379) are submitted for the same patient on the same date of service by the Same Individual Physician or Other Qualified Health Care Professional in facility POS 19, 21, 22, 23, 24, 26, 51, 52, or 61, only the E/M service will be reimbursed and the injection(s) (CPT 96372-96379) are not separately reimbursed, regardless of whether a modifier is reported.

Non-facility injection rule: When an injection (CPT 96372-96379) is performed in a place of service other than 19, 21, 22, 23, 24, 26, 51, 52, or 61 and an E/M service is provided by the same physician or qualified health care professional on the same date, only the injection(s) will be reimbursed and the E/M is not separately reimbursed unless the E/M meets criteria for a significant, separately identifiable service.

Modifier 25 application

A significant, separately identifiable E/M service is performed that is unrelated to the physician work inherent to the injection (beyond injection preparation, consent, safety oversight, supervision of staff, injection site assessment, and related tasks).
If the E/M meets this requirement, Modifier 25 may be reported on the E/M when billed in addition to CPT 96372-96379 and both the E/M (other than CPT 99211) and the injection may be reimbursed.

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

Preventive medicine exception: Preventive medicine E/M codes (CPT 99381-99412, 99429) may be reported with diagnostic and therapeutic injection services (CPT 96372-96379) and do not require Modifier 25; both are reimbursed separately.

HCPCS supplies: Standard tubing, syringes, and supplies identified by HCPCS as standard are considered included with injection and infusion services (CPT 96360-96379) and will not be separately reimbursed.

HCPCS drug codes are separately reimbursable when submitted with injection or infusion codes (CPT 96360-96379) by the same physician or qualified health care professional on the same date of service, subject to policy guidelines.

Different place of service same day: If the same physician performs an injection in a non-facility POS (not 19, 21, 22, 23, 24, 26, 51, 52, 61) and an E/M in a different POS on the same date, both the injection and the E/M may be reimbursed separately.

Procedure, Drug and Place-of-Service Coding

Injection/Infusion and drug codingCPTCovered

96360-96379	Injection and infusion services (includes HCPCS supply inclusions and drug code reimbursement per policy)
96372-96379	Therapeutic and diagnostic injection services (office injection CPTs)

HCPCS drug codesHCPCSCovered

HCPCS drug codes

Drugs administered with injections are separately reimbursable when billed same date by same provider per policy

E/M coding interactionsCPTNot Covered

99211	Low level E/M; not separately reimbursable with injection codes
99381-99412, 99429	Preventive medicine E/M codes; can be billed with injections without modifier 25

Facility POS restriction

Restricted facility POS listPlace of service codes 19, 21, 22, 23, 24, 26, 51, 52, and 61 — when an Injection and E/M are provided on the same date by the Same Individual Physician or Other Qualified Health Care Professional in these facility POS, only the E/M is reimbursed; CPT 96372-96379 are not separately reimbursed.

Non-facility contrastWhen the Injection is performed in a non-facility POS (not in the list above) and provided by the same individual, the injection (CPT 96372-96379) is reimbursed and the E/M is not separately reimbursed unless a significant, separately identifiable E/M is documented with Modifier 25.

RationaleCPT indicates therapeutic and diagnostic injection services typically require direct supervision and include patient assessment, consent, safety oversight, preparation and disposal of injection materials — activities presumed part of the injection procedure and not separately billable in facility POS.

Example implicationAn office visit for a scheduled injection where assessment and administration occur is integral to the injection and not separately reimbursable when performed in the restricted facility POS list.

Billing and Provider Actions for Injections and E/M

Billing Rule

Billing rules: injection vs E/M — facility restriction and Modifier 25

Do not bill a separate injection procedure for services performed in facility places of service listed; in those POS, only the E/M is reimbursed. In non‑facility settings, report the injection CPT (96372‑96379) as the reimbursable procedure and only report the E/M separately if it represents a significant, separately identifiable service with Modifier 25 (CPT 99211 is excluded).

Do not separately bill injection procedure reimbursement when the service and E/M are provided on the same date by the same provider in POS 19, 21, 22, 23, 24, 26, 51, 52, or 61; only the E/M is reimbursed in those settings.
In non‑facility POS (not in the list above), only the injection/infusion CPTs 96372‑96379 are reimbursed by default; an E/M may be reimbursed separately only if it is significant and separately identifiable and reported with Modifier 25.
CPT 99211 will not be reimbursed when submitted with therapeutic or diagnostic injection codes, with or without Modifier 25.

Key Definitions

Same Individual Physician or Other Qualified Health Care Professional

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

Context of useApplies when injection/infusion and E/M or HCPCS/drug codes are submitted on the same date to determine whether services are considered performed by the same provider for reimbursement rules.

Billing consequenceIf services are by the Same Individual Physician or Other Qualified Health Care Professional, facility POS rules and non-facility Modifier 25 rules apply as described in policy.

Injection

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

Examples of routes