The American Medical Association notes that infusion-and-hydration codes are among the most error-prone for coders; start/stop times, therapeutic vs. hydration classification, and documentation are often the reasons to blame.
This guide explains the correct use of procedure code 96365, including its definition, applicable clinical scenarios, required modifiers, and billing documentation rules to ensure compliance with CMS 2025 standards.
CPT Code 96365 Description
CPT code 96365 is the procedural code that is used to report the initial intravenous infusion of a therapeutic, prophylactic, or diagnostic substance or drug. AMA CPT 2026 defines that CPT code 96365 represents the first hour of IV infusion provided under the guidance of a qualified healthcare professional.
In practice, code 96365 defines the administration of a solution or medications into a patient’s vein during a continuous period, including up to sixty (60) minutes. Medications or solutions may include therapeutic infusions (ex., IV antibiotics), prophylactic infusions (e.g., preventative medications), and diagnostic infusions (e.g., contrast used in a test).
However, this code does not include chemotherapy or biologic infusions. These are, however, billed under specialized codes such as CPT 96413. Within drug administration coding, CPT 96365 serves as a foundational code for infusion therapy. It ensures proper billing for the skill, time, and supervision required to perform and monitor the IV infusion.
Accurate use of this code also supports compliance with CMS and payer documentation requirements for infusion therapy.
Clinical Scenarios Where CPT Code 96365 is Applicable
A clear understanding of the real-world applications of CPT code 96365 helps to make sure that the code is correctly used. Below are common therapeutic IV infusion coding examples that meet medical necessity and documentation criteria.
Micronutrient IV Infusion for Treating Vitamin Deficiencies
In a clinical environment, a patient might be infused with micronutrient therapeutic IV infusion to treat vitamin deficiencies. The supervision of the infusion is billed using CPT 96365. This is mainly because it signifies an initial intravenous infusion for a duration of one hour or less.
To guarantee the application of the code in compliance, providers must document:
- Exact beginning and end time of the infusion
- Names and dosages of administered agent(s)
- Details on patient monitoring and physician supervision
Prophylactic Antibiotic Infusion Before Surgery
A prophylactic infusion that is monitored before a procedure to prevent infection is also considered for CPT 96365. When performed on the same day of service as an E/M visit, documentation should establish the requisite linkage between the infusion and the E/M visit.
According to CMS billing rules, infusions and E/M services may both be billable when medically necessary, and it is clearly documented. This example demonstrates the importance of medical necessity documentation and payer compliance.
Applicable CPT 96365 Modifiers
Modifiers ensure precise claim processing and help communicate that multiple procedures or infusions were distinct or separately identifiable. For CPT code 96365, only the modifiers are used that are consistent with the CMS infusion administration rules 2025 and the NCCI edits guide.
Modifier 59 and Subcategory Modifiers X{EPSU}
- Modifier 59 for CPT 96365– This modifier is used when the IV infusion is discrete and separate from other services that are performed on the same day.
- XE (Separate Encounter) – This modifier is used when an Infusion is performed during a different patient encounter.
- XP (Separate Provider) – In using this modifier, the infusion is administered by a different clinician.
- XS (Separate Site) – When an Infusion is performed at a different anatomical site or vascular access point, the XS modifier is used.
- XU (Unusual Non-Overlapping Service) – This modifier applies when an Infusion does not overlap with other service components.
Proper use of these modifiers allows billing systems to bypass NCCI bundling edits, but incorrect or excessive use can trigger payer audits, denials, or compliance reviews.
How to Bill CPT Code 96365: Reimbursement and Compliance Guidelines
Do you want to boost your collection for intravenous infusions? Below are the essential IV infusion billing guidelines every provider and coder should follow.
CPT 96365 Documentation Requirements
Taking accurate notes of the infusion start and stop time is essential. The reported duration determines if CPT 96365 (initial hour) or CPT 96366 (each additional hour) is applied to the situation.
Incomplete or estimated times can lead to claim rejections under CMS infusion administration rules 2025.
Reporting Subsequent Infusions Beyond the Initial Hour
CPT code 96365 should only be billed once per encounter for the initial hour.
For infusions extending beyond that first hour, report:
- CPT 96366 – For each additional hour of the same drug.
- CPT 96367 – For sequential infusion of a new drug or substance.
This approach ensures accurate reporting of sequential infusion CPT coding and compliance with payer time-based billing rules.
Coding Concurrent Infusions Correctly
When multiple drugs are infused at the same time through separate IV lines, it’s considered a concurrent infusion.
Instead of 96365, CPT code 96368 is to report concurrent administration.
This difference between the codes prevents double-billing and maintains compliance with infusion administration guidelines.
Establishing Medical Necessity Through Complete Documentation
To meet payer criteria for CPT 96365 medical necessity, documentation should include:
- The symptoms a patient has and the resulting diagnosis
- Date of service and exact start/stop times
- Medications used, dosage, and the route of infusion
- Adverse reactions or monitoring details
Strong infusion therapy documentation supports compliance and successful CPT 96365 billing and reimbursement.
Pairing CPT 96365 with the Appropriate HCPCS Drug Code
CPT 96365 covers only the administration of the infusion—not the medication itself.
To bill the drug separately, pair it with the appropriate HCPCS J-code that identifies the infused substance.
Example:
- J0690 – Cefazolin injection, per 500 mg (for prophylactic antibiotic infusion).
Using the correct HCPCS code 96365 pairing ensures that both the infusion and the drug are reimbursed appropriately under Medicare billing for infusion therapy.
Can We Bill CPT Codes 96365 and 96413 Together?
CPT 96365 and CPT 96413 reflect different infusion administrations: therapeutic/prophylactic and chemotherapy. They can only ever be reported together if each infusion is performed at a different anatomical site or different evaluation and management encounter.
As an example, if a patient were to have a therapeutic infusion through one IV line and a chemotherapy infusion through a different IV, then the coder could report both codes.
Modifier 59 would be added to indicate distinct procedural services, regardless of NCCI edits for infusion coding. Proper documentation to include the site of infusion, time, and medical determination for infusion provides an appropriate defensive audit for payer acceptance.
Conclusion
Using CPT Code 96365 involves correctly recording all the details involved in the administration of an intravenous infusion of a medication or other substance for the initial hour.
Below is a brief reminder:
covers the administration of. Second, we shared some clinical scenarios where this code can be reported for billing accuracy.
- CPT 96365 indicates the first hour of a therapeutic, prophylactic, or diagnostic intravenous (IV) infusion
- For additional IV intravenous infusions, the appropriate codes CPT 96366 – 96368 should be used for administration that follows sequentially or concurrently to the initial service
- Modifiers, including 59, XE, XP, XS, XU, should only be properly applied and addressed when coded under National Correct Coding Initiative edits and CMS 2025 rules
- Assist the duration of the infusion and medical necessity should also be documented
- A HCPCS code to support the drug used in conjunction with infusion.
You can let the experts manage complex infusion coding, documentation, and payer compliance for you. Outsource your internal medicine billing to Nexus IO.
FAQs on CPT Code 96365
What is the difference between CPT codes 96365 and 96374?
Both these codes involve intravenous drug administration. However, both are used for different purposes:
- CPT 96365 – It is used for Initial intravenous infusion, up to one hour.
- CPT 96374 – This CPT code is used for the initial intravenous push of a therapeutic, prophylactic, or diagnostic substance.
- CPT 96375 – Each additional IV push of a new drug or substance.
Even small distinctions between these codes significantly impact billing accuracy and compliance.
Is CPT 96365 covered by Medicare?
Yes. However, when performed on the same day as an Evaluation and Management (E/M) service (e.g., CPT 99221), CPT 96365 is typically bundled into the E/M code under the Medicare Physician Fee Schedule (MPFS). In such cases, the infusion code is not separately payable unless properly justified with documentation and modifiers.
Can CPT 96365 be reported in an observation or inpatient setting?
Yes. CPT 96365 can be billed in both outpatient and inpatient settings, provided the service is performed by a qualified professional and separately documented. The code must represent direct supervision when applicable, as defined by Medicare hospital outpatient billing guidelines.
Can CPT 96365 be used for hydration therapy?
No. CPT 96365 must not be used for hydration services. Hydration infusions are reported separately using CPT 96360 (initial hour of hydration infusion) and CPT 96361 (each additional hour). Reporting hydration under CPT 96365 is noncompliant with NCCI edits and may result in claim denials.
