Rheumatologist Medical Coding

A Rheumatologist’s Dilemma—96372 vs. 96401

Type of drugs would fall under chemotherapy administration injection.

When new drugs are approved, the ACR receives inquiries concerning whether to code the drug administration as 96372 or 96401. The 2011 CPT describes procedural code 96372 as “typically requiring direct physician supervision for any or all purposes of patient assessment,” whereas 96401 “includes other highly complex drugs or highly complex biologic agents.” Keep in mind that both procedures require direct supervision, but the greatest difference in choosing the appropriate code is in the type of drug that is used.

Rheumatologist Medical Coding

CPT Code 96372

CPT code 96372 is defined as a “therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular.” Drugs that rheumatologists typically administered under 96372 are injectable gold sodium thiomalate (Myochrysine) and denosumab (Prolia).

CPT Code 96401

The CPT manual defines code 96401 as “chemotherapy administration, subcutaneous or intramuscular; nonhormonal antineoplastic.” This is a higher-reimbursed code than 96372 because of the intensity of the drugs administered under this code. The drugs used on this procedural code are:

·         Certain monoclonal antibody agents and other biologic response modifiers;

·         Nonradionuclide antineoplastic drugs; and

·         Antineoplastic agents that provide for the treatment of noncancer diagnoses.

Drugs that rheumatologists typically use that are administered using the code 96401 are methotrexate (Rheumatrex, Trexall) and certolizumab (Cimzia).

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