CPT Code 96365: Initial IV Infusion, Up to 1 Hour (Non-Chemo)

What is CPT code 96365?

CPT code 96365 is used for intravenous infusion for therapy, prophylaxis, or diagnosis; initial, up to 1 hour. This code is used when a qualified healthcare professional administers an initial intravenous infusion lasting up to one hour for therapeutic, prophylactic, or diagnostic purposes.

The current procedural terminology (CPT) code 96365 is specifically for non-chemotherapy infusions and is considered the primary procedure when reporting initial IV infusion services. The American Medical Association CPT manual indicates that this code covers the professional work associated with establishing IV access, confirming patency, monitoring the patient throughout the infusion, and managing the infusion up to one hour.

It's important to note that CPT code 96365 is distinctly different from codes used for chemotherapy infusion, IV push services, or hydration therapy, each with specific codes designated for their reporting. When medications are administered, continuous monitoring is required due to potential adverse reactions, and this initial intravenous infusion code is appropriate for reporting the service performed.

The 96365 CPT code should be used when:

• A therapeutic, prophylactic, or diagnostic substance is administered via intravenous infusion
• The infusion is the initial service provided (not following another infusion)
• The infusion duration is up to one hour
• The infusion is not for hydration, chemotherapy, or other specialized therapy that has its own specific code.

CPT code 96365 documentation requirements

Proper documentation is essential for accurate billing and appropriate reimbursement for infusion services. When documenting CPT code 96365, healthcare providers should ensure the medical record clearly indicates:

• Start and stop times of the IV infusion (to verify the infusion lasted up to one hour)
• Medication name, dosage, route, and rate of administration
• IV access site and method used to establish access
• Patient's response to treatment, including any adverse reactions
• Monitoring performed during the infusion (vital signs, etc.)
• Medical necessity for the infusion therapy
• Identity of the qualified healthcare professional providing the service

Documentation should also include any relevant patient-specific factors that influenced the need for infusion therapy, such as abnormal laboratory studies, inability to ingest fluids orally, or abnormal fluid losses.

For proper reimbursement and billing, it's critical to document whether just an IV line or an infusion pump was used to deliver medication efficiently. Additionally, if multiple drugs are administered through the same IV access, the medical record should clearly differentiate between initial, concurrent, and additional sequential infusions.

CPT code 96365 billing guidelines

Understanding the proper usage and billing guidelines for CPT code 96365 is crucial to ensure proper reimbursement and avoid compliance issues.

• CPT code 96365 represents only the initial infusion up to one hour.
• For infusions lasting longer than one hour, use the appropriate additional hour code (96366).
• When billing Medicare or other payers, this code should be paired with the appropriate J code for the specific medication administered.
• The 96365 code is reported only once per encounter, regardless of the number of separate IV sites accessed.
• Time-based reporting requires the infusion to last at least 31 minutes to report the full initial hour.