Initial intravenous infusion of a therapeutic, prophylactic, or diagnostic drug, other than chemotherapy or hydration, lasting more than 15 minutes and up to one hour.
- Medicare
- $67.14
- Work RVU
- 0.21
- Global, days
- Region
- General
Documentation requirements
What must appear in the operative or office note to support the claim.
Source · Editorial brief grounded in 4 cited references ↓
- Drug name, dose, route, and NDC or J-code with units
- Infusion start and stop times showing more than 15 minutes
- Medical necessity tied to a diagnosis (for example osteoporosis, osteomyelitis)
- Physician order and supervising provider present in the office suite
- IV site and any second access site with reason
- Patient monitoring and tolerance during the infusion
Applicable modifiers
Modifiers commonly billed with this code.
Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual
What this code covers
Source · Editorial summary grounded in 4 cited references ↓
96365 is the first hour of an IV infusion of a drug given for treatment, prevention, or diagnosis. The infusion has to run longer than 15 minutes. Anything 15 minutes or shorter is an IV push (96374).
In ortho, this shows up in practices that run an in-office infusion suite. The common cases are zoledronic acid for osteoporosis, IV antibiotics for osteomyelitis or a post-op joint infection, and IV iron before joint replacement. The drug itself is billed separately with its J-code and units.
Denials usually start with the initial code. Only one is billed per encounter. In the office, it goes to the service that was the main reason for the visit, not whichever drug started first. Facilities follow the hierarchy instead (chemotherapy, then therapeutic, then hydration). A second initial code needs a separate IV site that was medically necessary, with modifier 59 or XU. Start and stop times must be in the record, or the payer will deny or downcode to a push. The physician bills this code only in the office; in a hospital outpatient department, the facility bills it.
RVU & reimbursement
Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.
Source · CMS Physician Fee Schedule, RVU26A · January 2026
Work RVU vs. total RVU
The work RVU (0.21) is the surgeon's own effort — the figure physician pay and productivity targets are built on. The total RVU (2.01) adds practice overhead and malpractice, and is what drives the Medicare payment below.
| Work RVU | 0.21 |
| Practice expense RVU | 1.76 |
| Malpractice RVU | 0.04 |
| Total RVU | 2.01 |
| Medicare national rate | $67.14 |
| Global period | days |
Payment by site of service
Medicare pays different rates by setting. HOPD typically pays substantially more than ASC for the same procedure.
Source · CMS OPPS Addendum B·ASC HCPCS payment rates·2026
| Setting | Medicare rate (national) |
|---|---|
Office (PFS non-facility) Procedure performed in physician's office | $67.14 |
HOPD (APC 5693) Hospital outpatient department | $217.31 |
Common denial reasons
The recurring reasons claims for CPT 96365 get rejected.
Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓
- Missing start and stop times
- Infusion lasted 15 minutes or less and should have been a push
- Two initial codes billed without a separate medically necessary IV site
- Billed by the physician in a facility setting where the facility owns the service
- Drug J-code missing or units do not match the dose
- Drug not covered for the diagnosis under the payer's policy
Frequently asked questions
Source · Generated from the editorial pipeline, verified against 4 cited references ↓
01How long does an infusion have to be to bill 96365?
02Can I bill 96365 twice in one day?
03Is zoledronic acid billed with 96365 or chemo codes?
04Does an E/M visit on infusion day need modifier 25?
Sources & references
Editorial content was developed using the following public sources.
Mira Scribe
Mira Scribe records the drug, dose, and infusion start and stop times along with the reason for the infusion, so the chart supports the initial hour and any add-on time.
See how Mira captures CPT 96365 documentation