IV infusion, first hour (CPT 96365): what Medicare pays
On a hospital bill, CPT 96365 is the code for: Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less. Here is what Medicare pays for it, what is billed on average, and how to question the line on your bill.
CPT 96365 at a glance
| Medicare average allowed amount | $60.45 |
|---|---|
| Average amount billed to Medicare | $222.72 |
| Billed vs. allowed | 3.7 times |
| Services in the data | 1,390,277 |
| Setting and year | Office or clinic, national average, 2024 |
What this code is
This code is for giving a medicine or fluids by injection or through an IV, not for the medicine itself.
Why your hospital bill can show more
Medicare pays a national amount for each code. Hospitals set their own list prices, called the chargemaster, so a hospital bill can show a much higher amount for the same code. In a hospital or an emergency room, a separate facility charge is often added. Medicare's amount is not a price the hospital must accept, but it is a fair reference to negotiate.
Common billing problems with CPT 96365
Two "first" injections or infusions
Medicare coding rules allow one "initial" injection or infusion per visit, unless two separate IV sites were needed. If your bill shows more than one, ask which applies.
A separate facility charge
In a hospital, the facility usually bills its own line for the room and staff, and the doctor can bill separately. Ask the hospital to list each part.
No code on the line
If your bill shows a total without codes, ask for a fully itemized bill. Without codes, nobody can check the charges.
How to question this charge
- Ask the hospital for a fully itemized bill, with the code, date, quantity and price of every line.
- Compare the line with the Medicare amount above.
- Ask in writing for a fair price, the lowest amount they will accept, and any discount for paying in full or for patients without insurance.
- Ask for the hospital's financial assistance policy.
BillCheck reads a photo of your bill on your phone, compares every line and writes the letter. Check my bill.
Related codes
- CPT 96366: IV infusion, each additional hour
- CPT 96374: IV push, first drug
- CPT 96375: IV push, each additional drug
- CPT 96360: IV hydration, first hour
- CPT 96361: IV hydration, each additional hour
- CPT 96372: Injection into a muscle or under the skin
Frequently asked questions
How much does CPT 96365 cost?
It depends on where it is done. In 2024, Medicare's average allowed amount for CPT 96365 in an office setting was $60.45, and providers billed Medicare $222.72 on average. Hospitals can bill more. If you have no insurance, ask for the self-pay price before you pay.
Can a bill show two initial injections?
Medicare coding rules allow one initial injection or infusion per visit unless two separate IV sites were needed. Ask which applies.
What is the difference between CPT 96365 and CPT 96366?
CPT 96365 is IV infusion, first hour. CPT 96366 is IV infusion, each additional hour. Medicare's average allowed amounts were $60.45 and $19.46 in 2024.
How do I question this charge?
Ask for an itemized bill, compare the line with the Medicare amount, then ask in writing for a fair price and for financial assistance. BillCheck writes the letter for you.
Sources
- CMS, Medicare Physician & Other Practitioners by Geography and Service, 2024: national averages, office setting.
- CMS, NCCI Policy Manual, chapter 11: one initial injection or infusion per visit.
- IRS, financial assistance policy of nonprofit hospitals, section 501(r)(4).