The guidelines described below apply to claims processed under the new claims processing system. The guidelines should be used for filing all private business claims.
The code edit changes described in the guidelines below will not override HMSA's existing medical policies.
Modifiers
When billing for injection or intravenous infusion with other services, it is important to bill accurately.
When the injection/infusion code is billed with an Evaluation & Management (E/M) visit, a modifier code must be appended to the E/M code to ensure that both services are paid when appropriate. Modifier 25 would generally be used for this purpose, if criteria for the use of this modifier are met.
When an injection/infusion code is billed with another code from CPT (e.g., surgery, radiology) a modifier code may be appended to the injection/infusion code, if criteria for the use of the modifier are met. Modifiers that may be used for this purpose include 59, LT, RT and other site specific modifiers. Practitioners are urged to familiarize themselves with the criteria listed in CPT and in the following policies.
Modifier codes should only be used when the service meets the criteria described in CPT and HMSA's policies. HMSA will perform postpayment reviews of modifier usage as needed to verify modifiers were used as described. If postpayment review indicates that modifiers were not used appropriately, HMSA will request return of any overpayment. See Benefit Overpayment.
Specific Edits
The following code edits apply to injections or infusions billed with other services.
If the code in the left column is billed with any of the codes in the right column, one of the codes will deny. The reason for the denial may vary because:
- The codes may be mutually exclusive. Mutually exclusive procedures are two or more procedures that are usually not performed during the same patient encounter on the same date of service.
- Multiple codes may have been billed, which taken together are more accurately described by a more comprehensive procedure code
- The code may be incidental to another code. An incidental procedure is a procedure carried out at the same time as a more complex primary procedure; however, the incidental procedure requires little additional physician resources and/or is clinically integral to the performance of the primary procedure.
However, unless otherwise indicated, a modifier may be used to request separate payment, if criteria for the use of the modifier are met.
Injections/intravenous infusion billed with E/M codes
| E/M Descriptor | CPT Codes for Injection/Infusion |
|---|---|
| Office visits - established patient | 20550, 20551, 20552, 20553, 27096, 95120, 95125, 95130-95134, 96401-96409, 96413, 96416, 96420, 96446, 96450, 96542 |
| Office visits - new patient | 95120, 95125, 95130-95134, 96401-96409, 96413, 96416, 96420, 96446, 96450, 96542 |
| Outpatient consultations | 51600, 62270, 62320-62321, 64483, 64493, 64520 |
| ER visits | 96360, 96372, 96374, 96375 |
| Preventive service exams | 96372-96375 |
Standard injection/infusion codes from the Medicine section of CPT billed with other types of services
| CPT Code | CPT Code(s) |
|---|---|
| 96360 | 36430, 43239, 72193-72194 |
| 96365 | 20551, 20605, 36556, 64479, 64483, 64633, 72193-72194, 96409, 96413 |
| 96372 | 10060-10061, 10120-10121, 11300-11303, 12001-12002, 12032, 10160, 17000, 17004, 20550, 20552-20553, 20600, 20605, 20610, 29515, 30210, 42700, 51701, 55700, 56740, 57065, 57456, 58100, 58322, 59000, 59820, 59840-59841, 60300, 69210, 69220, 72193-72194, 74170, 95115, 95117, 95165, 95170, 96409, 96413, 96416 |
| 96374 | 10060, 16025, 20550, 55700, 72193-72194, 74170, 95115, 95117, 95165, 95170, 96409, 96413, 96416 |
Other injection/infusion codes billed with various types of service
| CPT Code(s) for Injection/ Infusion |
CPT Code(s) for Other Services |
|---|---|
| 20552-20553 | 64405 |
| 64450 |
29125, 54150, 55700 Note: Newborn circumcision is not a benefit of all HMSA plans. Coverage varies by plan. |
| 95125 |
95144-95170 Note: Injection is an integral component to these services and may not be separately paid, even if billed with a modifier. |
| 96409 | 96413 |
| 96409, 96413, 96416 | 36000 |
| 96413 | 96409 |
| 96401-96402, 96405-96406, 96409, 96413, 96416, 96420, 96422, 96425 |
96523 Note: Per CPT guidelines, this code should not be reported if an injection or infusion is provided on the same day. This code will not be paid with an injection or infusion code, even if a modifier is appended to one of the codes. |
Note: The above lists are not all inclusive and are subject to change.
Please be sure to use the most up-to-date industry-standard procedure, revenue, and diagnosis codes from the current CPT ®'', HCPCS Level II, and ICD-10-CM manuals, as recommended by the American Medical Association (AMA), the Centers for Medicare & Medicaid Services (CMS), and the American Hospital Association.
** Codes may not be all inclusive as the AMA and CMS code updates may occur more frequently.
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform |