Yes — a non-chemo drug given SC or IM during a chemotherapy visit is a separate service from the infusion. The 96413 / 96372 edit (column 2 = 96372, modifier indicator 1) means the injection line carries XU or 59. A non-chemo drug pushed into the IV line instead is 96375, and a chemo/complex SC drug is 96401.
The 96372 / 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:
96372 (column 2) denies as included in 96413 (column 1) unless the 96372 line carries a distinct-service modifier — XU or 59 — and the record supports a distinct service.
Column 1 96413 · column 2 96372 · edit effective January 2009.
Same edit, same direction: column 1 96413, column 2 96372, since January 2009. A UB-04 carrying 96413 and 96372 is adjudicated exactly as the CMS-1500 is.
Denosumab or zoledronic-acid-alternative bone agents, growth-factor products given the same day where a protocol allows it, B12, and steroid or antihistamine injections by the IM route all produce this pair on infusion-centre claims. The chemotherapy infusion is the encounter’s initial service; the injection is not an add-on to it (there is no “each additional injection” code) but a service in its own family, reported at full value with its own drug line.
The NCCI edit pairs 96413 (column 1) with 96372 (column 2) at modifier indicator 1 and has since January 2009. Billed bare, 96372 denies as included in the infusion. The modifier that opens it is XU (unusual non-overlapping service), or 59 where a payer still expects it; it goes on 96372 only. The documentation that supports it is the MAR: a different drug, by the SC or IM route, with a site.
Units and MUEs are generous on this pair — 96372 allows 4 per date of service in the office — but the drug lines are where audits land. Denosumab 120 mg is 120 units of J0897 and, like most single-dose products, carries JZ when the full syringe was given. The infusion’s hours are counted on the chemotherapy drug alone: 90 minutes is 96413 with no additional hour.
Distinct by route and substance, not by encounter: the injected drug is not the infused drug and was not delivered through the IV. If the same non-chemo drug had been pushed through the line, it would be 96375 and no modifier question would arise.
| Code | Descriptor | Practitioner MUE / day | Facility MUE / day | Adjudication · rationale |
|---|---|---|---|---|
96372 | therapeutic, prophylactic or diagnostic injection, SC or IM | 4 | 5 | MAI 3 · Clinical: Data |
96413 | chemotherapy or highly complex biologic IV infusion, initial hour | 1 | 1 | MAI 3 · Code Descriptor / CPT Instruction |
96372 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 96372 / 96413 answer rests on H10 in the claim builder’s rule set (source: CPT 2026 hydration / therapeutic infusion guidelines · CMS Pub 100-04 ch. 12 §30.5), the rule it applies when it places a line by route:
…a subcutaneous or intramuscular therapeutic injection reports 96372 (96401 chemo/biologic)… Full text of H10
Related hierarchy rules for this claim: H5 (CPT 2026 hydration / therapeutic infusion guidelines).
CO-97 on 96372 with 96413. Append XU to 96372 and resubmit with the MAR. If the drug was given IV, correct the code to 96375 (no modifier, no edit against 96413) rather than modifying 96372.
The median payer contract pays 126–140% of Medicare on 96372, 96413. On 96372 the highest payer median is Blue Shield of California’s $67.48 and the lowest BCBS Arizona’s $10.96, against Medicare’s $15.36; Blue Shield of California is highest on 2 of the 2 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 |
|---|---|---|---|---|
96372 | $15.36 | $19.31 (126%) | $17.22–$24.16 | 37 |
96413 | $133.27 | $187.00 (140%) | $170.46–$217.49 | 36 |
3,475 payer×state medians for 96372, 96413 from 37 payers’ Transparency-in-Coverage files (2026-Q2-06); Medicare = national non-facility PFS.
This claim priced by your payer — Herceptin’s rate on the drug line, 96372 and 96413 at the payer’s contracted amount, the payer’s policy on Herceptin (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.
Yes: pegfilgrastim (J2506, or the biosimilar Q-codes) by the SC route on a chemotherapy day is 96372-XU alongside 96413, with the growth factor on its own drug line. The same-day question is a coverage rule, not a coding one — the administration coding does not change.
That is 96401, not 96372, because daratumumab is a complex biologic. 96401 has no PTP edit against 96413, so it bills without a modifier as the additional-drug line. Only non-chemo, non-complex substances use 96372.
Each different non-chemo drug injected SC or IM is one unit of 96372, up to the practitioner MUE of 4 per date of service, every unit carrying the distinct-service modifier against the 96413. The chemotherapy code stays at one unit (its MUE is 1 per day).