Not as two initial infusions. When a chemotherapy or complex-biologic infusion (96413) is on the encounter, a non-chemo drug infused before or after it is 96367 (sequential) or 96368 (concurrent), never a second initial 96365. 96365-XS (separate access site) or 96365-XE (separate encounter) with 96413 is for those two situations only.
The 96365 / 96413 pair as it stands in the CMS PTP tables for 2026q3 (as of 2026-07-01), identical on the practitioner and hospital-outpatient tables:
96365 (column 2) denies as included in 96413 (column 1) unless the 96365 line carries a distinct-service modifier — XS for a separate access site, XE for a separate encounter, or 59 — and the record supports a distinct service.
Column 1 96413 · column 2 96365 · edit effective January 2009.
Same edit, same direction: column 1 96413, column 2 96365, since January 2009. A UB-04 carrying 96413 and 96365 is adjudicated exactly as the CMS-1500 is.
This is the everyday oncology and rheumatology claim: a steroid, an antihistamine or IVIG infused around a monoclonal antibody. In physician reporting the initial code goes to the primary reason for the encounter — the antibody — and facility reporting gets there through CPT’s hierarchy, which puts the chemo/complex family on top; either way 96413 is the initial service whatever ran first, and every other infused drug becomes an add-on to it. Sequential (one after the other, through the same access) is 96367 up to an hour, with 96366 for its additional hours; running at the same time is 96368, reportable once per date of service.
The 96413 / 96365 PTP edit carries modifier indicator 1 and has been on the table since January 2009. It denies 96365 as included in 96413 unless the 96365 line carries XS (separate structure — a second IV access site the drugs needed because they could not share one), XE (a separate encounter on the date) or 59 where the payer has not adopted the X modifiers — and the modifier is only defensible when the record shows that site or encounter.
Hour counting stays with the initial drug. In the example rituximab’s 240 minutes produce 96413 plus three units of 96415 (each additional hour needs more than 30 minutes into it); the 30-minute steroid infusion is one unit of 96367 and never adds hours of its own. Both add-ons require the initial code on the same claim to be payable at all.
Two access sites used because the drugs were incompatible in one line, or two distinct encounters on the same date. Either supports 96365-XS or 96365-XE alongside 96413. A long chair day, a different nurse, or the steroid finishing before the antibody started does not.
| Code | Descriptor | Practitioner MUE / day | Facility MUE / day | Adjudication · rationale |
|---|---|---|---|---|
96365 | therapeutic/prophylactic/diagnostic IV infusion, initial hour | 1 | 2 | MAI 3 · Clinical: Data |
96413 | chemotherapy or highly complex biologic IV infusion, initial hour | 1 | 1 | MAI 3 · Code Descriptor / CPT Instruction |
96365 and 96413 are MAI 3: units are summed across the date of service, and a documented medical-necessity appeal can pay units above the limit. Other codes: MUE lookup.
The 96365 / 96413 answer rests on H1 in the claim builder’s rule set (source: NCCI Policy Manual 2026 ch. XI §B.2), the rule it applies when it places the initial-service line:
…For a patient encounter, only one "initial" service code may be reported unless it is medically reasonable and necessary that the drug or substance administrations occur at separate intravenous access sites.… Full text of H1
Related hierarchy rules for this claim: H5 (CPT 2026 hydration / therapeutic infusion guidelines) and H6 (CPT 2026 hydration / therapeutic infusion guidelines · NCCI Policy Manual 2026 ch. XI §B.16).
CO-97 on 96365 when billed with 96413 and no modifier. Rebill the second drug as 96367 (sequential) or 96368 (concurrent); use 96365-XS or 96365-XE only if the record shows the separate site or encounter, and be ready to send the infusion flowsheet.
The median payer contract pays 120–151% of Medicare on 96365, 96413, 96415, 96367. On 96365 the highest payer median is Blue Shield of California’s $268.22 and the lowest BCBS Arizona’s $41.15, against Medicare’s $67.14; Blue Shield of California is highest on 4 of the 4 lines. Pick a state below for each payer’s own number where you bill.
| Code | Medicare (PFS, office) | Median payer contract | Middle half of payer medians | Payers |
|---|---|---|---|---|
96365 | $67.14 | $80.58 (120%) | $76.35–$94.57 | 37 |
96413 | $133.27 | $187.00 (140%) | $170.46–$217.49 | 36 |
96415 | $28.39 | $42.89 (151%) | $38.63–$48.38 | 37 |
96367 | $29.73 | $38.45 (129%) | $35.00–$43.60 | 37 |
6,991 payer×state medians for 96365, 96413, 96415, 96367 from 37 payers’ Transparency-in-Coverage files (2026-Q2-06); Medicare = national non-facility PFS.
This claim priced by your payer — Rituxan’s rate on the drug line, 96365 and 96413 and 96415 and 96367 at the payer’s contracted amount, the payer’s policy on Rituxan (prior auth, covered diagnoses), and the patient’s share — is the same claim in your free account.
Price this claim for your payer — start free →
Free 30-day trial, no card. The claim above opens in Claim Check with the drug, dose, setting and your payer already filled in.
No. Sequence does not choose the initial code. For a physician office the initial service is the primary reason for the encounter — the rituximab — and a facility applies CPT’s hierarchy, where chemotherapy or complex-biologic infusion (96413) outranks a therapeutic infusion (96365). Both roads make rituximab the initial service even though it started an hour later.
96367 covers the first hour of a sequential new drug; each additional hour beyond it, when the infusion runs more than 30 minutes into that hour, is a unit of 96366. A two-hour sequential steroid infusion is 96367 × 1 plus 96366 × 1, still with 96413 as the encounter’s initial code.
Not on Medicare or any payer applying the NCCI practitioner or hospital tables: the 96413 / 96365 edit denies 96365 as included. The pair pays only when 96365 carries XS, XE or 59 for a documented separate site or encounter — or when the second infusion is correctly recoded as 96367 / 96368, which has no edit against 96413 at all.