Injection and Infusion Services Policy, Professional - Reimbursement Policy - UnitedHealthcare Commercial Plans
This UnitedHealthcare reimbursement policy is aligned with the American Medical Association (AMA) Current Procedural Terminology (CPT®) and Centers for Medicare and Medicaid Services (CMS) guidelines.
This policy describes reimbursement for therapeutic and diagnostic Injection services (CPT codes 96372-96379) when reported with evaluation and management (E/M) services.
This policy also describes reimbursement for Healthcare Common Procedure Coding System (HCPCS) supplies and/or drug codes when reported with Injection and Infusion services (CPT codes 96360-96549 and G0498).
For the purpose of this policy, the Same Individual Physician or Other Qualified Health Care Professional is the same individual rendering health care services reporting the same Federal Tax Identification number.
Find your specific codes below.
This policy contains more codes than can be displayed on one screen. Find your specific code below.
Click to Download: Injection and Infusion Services Policy, Professional - Reimbursement Policy - UnitedHealthcare Commercial Plans
Questions and Answers
Q: Will UnitedHealthcare separately reimburse for a therapeutic and diagnostic Injection service performed in a facility in addition to the E/M service provided on the same date of service by the Same Individual Physician or Other Qualified Health Care Professional?
A: Therapeutic and diagnostic Injection services performed in an emergency room, ambulatory surgical center, and facility (POS 19, 21, 22, 23, 24, 26, 51, 52, and 61) are not separately reimbursed from the E/M service. Refer to the “incident to” guidelines within the Professional/Technical Component Policy for additional guidelines pertaining to CPT codes 96360-96549 and G0498 performed in a facility setting.
Q: Will UnitedHealthcare separately reimburse for the office E/M service performed with the therapeutic or diagnostic Injection given on the same date of service by the Same Individual Physician or Other Qualified Health Care Professional?
A: No, UnitedHealthcare does not separately reimburse an E/M service in addition to the Injection service. When an E/M Injection service is submitted for the same member on the same date of service, there is a presumption that the E/M service represents the physician work that is part of the Injection procedure. CPT indicates therapeutic and diagnostic Injection service(s) typically require(s) direct supervision for any or all purposes, of patient assessment, provision of consent, safety oversight, intra-service supervision of staff, preparation and disposal of the Injection materials, and the required practice training of staff for competency in the administration of Injections/Infusions.
Example: The following example describes an E/M service that is not separately reimbursed from a therapeutic and diagnostic Injection: A physician or nurse sees a patient in the office for a scheduled Injection, asks about prior allergic reactions, instructs on post-injection care of the Injection site and administers the Injection. The E/M service is integral to the Injection and is not separately reimbursable.
Q: Will UnitedHealthcare separately reimburse for an office E/M service when provided in other than POS 19, 21, 22, 23, 24, 26, 51, 52, and 61 if a significant, separately identifiable E/M service is performed in addition to the therapeutic or diagnostic Injection given on the same date of service by the Same Individual Physician or Other Health Care Professional?
A: Yes, UnitedHealthcare will separately reimburse for an E/M service (other than CPT 99211) unrelated to the physician work associated with the Injection service (CPT 96372-96379) when reported with a Modifier 25. Refer to Q&A #2 for a description of the physician or work typically included in the allowance for the therapeutic and diagnostic Injection service. When an E/M service and an Injection or Infusion service are submitted for the same enrollee on the same date of service, there is a presumption that the E/M service is part of the procedure unless the physician identifies the E/M service as a separately identifiable service.
Example: The following example describes an E/M service that is separately identifiable from a therapeutic and diagnostic
Injection: A physician evaluates a patient's symptoms, diagnoses a serious streptococcal infection, and treats with injectable penicillin. The diagnostic process is separately identifiable from the process of the Injection. The E/M service (other than CPT code 99211) should be reported with Modifier 25 and is reimbursed separately from the therapeutic Injection code and the drug code for the penicillin.
Q: If a HCPCS drug code is submitted in addition to the Injection or Infusion codes (CPT 96360-96549 and G0498) in a non-facility setting and no other service is performed on the same date of service, will UnitedHealthcare separately reimburse for both of these?
A: Yes, UnitedHealthcare would reimburse for both the HCPCS drug code and the Injection or Infusion code (CPT 96360-96549 and G0498) under the guidelines of this policy.
Q: Will UnitedHealthcare reimburse the same physician for both an injection (96372-96379) and an E/M service code on the same date of service if each is performed in a different place of service?
A: Yes, UnitedHealthcare will separately reimburse the same physician for both an Injection procedure and E/M service on the same date of service if each is performed in a different place of service (POS) and the Injection was provided in a POS other than 19, 21, 22, 23, 24, 26, 51, 52, and 61. For example, if the patient only receives an Injection at a physician's office (POS 11) and later that day the patient is admitted to the hospital (POS 21), both services, the Injection service performed at the physician's office and the E/M performed later that day at the hospital, would be separately reimbursed under the guidelines of this policy because the Injection service and E/M service were performed in different locations by the same physician on the same date of service. Injection services are not reimbursable when provided in POS 19, 21, 22, 23, 24, 26, 51, 52, and 61.
Q: If a Preventive Medicine E/M service is reported with an Injection (96372-96379), will UnitedHealthcare reimburse for both?
A: Yes, UnitedHealthcare will reimburse for the Injection procedure and the Preventive Medicine E/M Code. When an E/M service and a procedure are submitted for the same enrollee on the same date of service, there is a presumption that the E/M service is part of the procedure unless the physician identifies the E/M service as a separately identifiable service. Since the Injection procedure does not include the components of a Preventive Medicine E/M service, the Injection can be reported separately and the Preventive Medicine E/M code does not need a modifier to indicate it is distinct or separate from the Injection procedure.