Yes, with no modifier. There is no NCCI edit between 96413 and 96401 on the practitioner or hospital table: a chemotherapy or complex-biologic injection and a chemotherapy infusion are different routes in the same family, and each is reported when each drug is separately ordered and documented.
The 96401 / 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:
CMS lists no procedure-to-procedure edit between 96401 and 96413 on this table (2026q3). Each code is adjudicated on its own; the CPT hierarchy decides which code carries each service.
CMS lists no procedure-to-procedure edit between 96401 and 96413 on this table (2026q3). Each code is adjudicated on its own; the CPT hierarchy decides which code carries each service.
Bortezomib with rituximab, subcutaneous daratumumab with an IV partner, and the growing set of subcutaneous formulations given alongside an infused agent make this one of the cleaner combinations on a chemotherapy claim. The hierarchy still applies — the infusion is the encounter’s initial service — but 96401 is not an initial IV code and competes with nothing: it is reported once per SC or IM chemo/complex substance, up to the practitioner MUE of 3 per date of service.
Because CMS never wrote a 96413 / 96401 PTP pair, there is no column 2, no modifier indicator and no distinct-service modifier to add. A 59 or XU on 96401 here is harmless on most systems but signals to an auditor that the coder expected an edit that does not exist; leave it off. The hours are counted on the infused drug alone: 240 minutes of rituximab is 96413 plus 96415 × 3, and the subcutaneous bortezomib adds no time.
Where this pair goes wrong is the drug, not the administration: a subcutaneous denosumab, steroid or antiemetic on the same day is 96372 (with the 96413 / 96372 edit and its modifier), not 96401, and a second dose of the same subcutaneous chemotherapy at one sitting is still one unit. The bortezomib line in the worked claim also shows the JW waste split for the partially used single-dose vial.
No separate-encounter or separate-site condition applies; the two codes are different routes and coexist on one encounter. The only condition is classification: the injected substance must itself be a chemotherapy or highly complex biologic to earn 96401.
| Code | Descriptor | Practitioner MUE / day | Facility MUE / day | Adjudication · rationale |
|---|---|---|---|---|
96401 | chemotherapy or highly complex biologic injection, SC or IM | 3 | 4 | MAI 3 · Clinical: Data |
96413 | chemotherapy or highly complex biologic IV infusion, initial hour | 1 | 1 | MAI 3 · Code Descriptor / CPT Instruction |
96401 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 96401 / 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: H6 (CPT 2026 hydration / therapeutic infusion guidelines · NCCI Policy Manual 2026 ch. XI §B.16).
A denial on 96401 with 96413 is rarely the PTP table, since no edit exists. Check the drug’s classification on the payer’s administration policy (some list specific biologics as 96372), the MUE on 96401 (3 per day), and whether the claim accidentally carried two initial IV codes for the infused drugs.
The median payer contract pays 134–151% of Medicare on 96401, 96413, 96415. On 96401 the highest payer median is Blue Shield of California’s $263.41 and the lowest BCBS Arizona’s $53.36, against Medicare’s $71.81; Blue Shield of California is highest on 3 of the 3 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 |
|---|---|---|---|---|
96401 | $71.81 | $96.46 (134%) | $83.62–$102.54 | 37 |
96413 | $133.27 | $187.00 (140%) | $170.46–$217.49 | 36 |
96415 | $28.39 | $42.89 (151%) | $38.63–$48.38 | 37 |
5,231 payer×state medians for 96401, 96413, 96415 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, 96401 and 96413 and 96415 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.
Rituximab SC is 96401 (it is a complex biologic given subcutaneously) and the IV chemotherapy is 96413; no edit, no modifier, two drug lines. If the day’s IV agent is a non-chemo drug instead, the infusion would be 96365 and 96401 still bills alongside it — also without an edit.
No. There is no 96413 / 96401 PTP edit on either NCCI table, so there is nothing for a modifier to bypass. The distinct-service modifiers are for column-2 codes of an existing edit; adding one here does not change payment and can draw audit attention.
Yes, one unit per distinct chemotherapy or complex-biologic substance injected, within the practitioner MUE of 3 per date of service (4 on the facility table), each with its own J-code line. The infusion remains 96413 × 1.