Billing A7003 AND APPEAL Medicare denial 96372

Can we bill A7003 when giving nebulizer treatments

Ans :  Yes.

Note : When we give a nebulizer treatment we bill 94640 and A7003 since we do have to purchase the administration set but we've not billed J7619 since more often than not we use unit-dose Albuterol that's been provided by a drug company as an office sample. If the modifiers apply to our office then it will work but I am under the impression it is for the patient You should bill for both the E/M + modifier-25 and the neb treatment. Don't forget supplies (such as A7003/A7015). We also often use drug samples for treatment, but if our drug supply is used, we bill the J-code for the drug.

Can I appeal Medicare denial of 96372

Ans : No.

Note  : 2009 Annual CPT Update; addition to CPT code 96372, removal of CPT code 90772. "CMS National Coverage Policy" section removed duplicative wording. Under "Documentation Requirements" removed duplicate reference cited previously in CMS National Coverage Policy" and removed CPT code 90772 and added CPT 96372 to statement that this CPT code will be allowed for indicated diagnoses beyond those in this LCD. Added CPT code 96372 under "ICD-9 Codes that Support Medical Necessity" to statement which indicates the code is for other LCDs and these specific ICD-9 codes do not apply to this particular code. "Sources of Information and Basis for Decision" references placed in AMA citation format.96372 and 96402 will be allowed for indicated diagnoses beyond those in this LCD. Chart documentation must support the diagnosis on the claim, and be made available to Medicare upon request.


This Oxford 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 HCPCS code G0498).

For the purpose of this policy, same individual physician, hospital, ambulatory surgical center or other health care professional is the same individual, hospital, ambulatory surgical center or other health care professional rendering health care services reporting the same Federal Tax Identification number.


Injections (96372-96379) and Evaluation and Management Services by Place of Service

Facility, Emergency Room, and Ambulatory Surgical Center Services

Per CPT and the CMS National Correct Coding Initiative (NCCI) Policy Manual, CPT codes 96372-96379 are not intended to be reported by the physician in the facility setting. Thus, when an E/M service and a therapeutic and diagnostic injection service are submitted with CMS Place of Service (POS) codes 19, 21, 22, 23, 24, 26, 51, 52, and 61 for the same patient by the Same Individual Physician or Other Health Care Professional on the same date of service, only the E/M service will be reimbursed and the therapeutic and diagnostic Injection(s) are not separately reimbursed, regardless of whether a modifier is reported with the injection(s).

Administration Fee for injectable(s) - In accordance with CPT guidelines the administration fee for injectable(s) codes 96372 – 96377 will be covered in addition to the cost of the drug(s), which are eligible for coverage.

Codes for Drug Administration

Drug administration services are reported on claim forms in both the physician office (CMS-1500) and hospital outpatient (CMS-1450) sites of care using the CPT® coding system. Consider using the following CPT® code for reporting STELARA® injection services:

Code Description

96372 Therapeutic, prophylactic, or diagnostic injection; subQ or intramuscular

Item 19—Additional information is generally not required when reporting J3357 (Ustekinumab, for subcutaneous injection, 1 mg). Payer requirements for information and codes may vary.

* Item 21—Indicate diagnosis using appropriate ICD-10-CM codes. Use diagnosis codes to the highest level of specificity for the date of service and enter the diagnoses in priority order. The “ICD Indicator” identifies the ICD code set being reported. For ICD-10-CM diagnoses, enter 0 (zero) as a single digit between the vertical, dotted lines.

Item 24A—If line item NDC information is required, it will be entered in the shaded portion of Item 24A. For more information on NDC coding, please see Core Immunology Billing Guide p. 6. Payer requirements for NDC entries may vary.*

Item 24D—Indicate appropriate CPT® and HCPCS codes and modifiers,  if required.

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