Yes, when the visit was a significant, separately identifiable evaluation beyond watching the infusion — and then modifier 25 goes on 99214, because in the 96365 / 99214 edit (in place since October 2020) the E/M is the column-2 code. A nurse-only check-in with no separate problem addressed does not bill an E/M at all, and a 99211 never bills alongside an infusion regardless of what modifier is appended.
The 99214 / 96365 pair as it stands in the CMS PTP tables for 2026q3 (as of 2026-07-01), identical on the practitioner and hospital-outpatient tables:
99214 (column 2) denies as included in 96365 (column 1) unless the 99214 line carries a distinct-service modifier — 25 on the E/M — and the record supports a distinct service.
Column 1 96365 · column 2 99214 · edit effective October 2020.
Same edit, same direction: column 1 96365, column 2 99214, since October 2020. A UB-04 carrying 96365 and 99214 is adjudicated exactly as the CMS-1500 is.
Since 1 October 2020 the NCCI practitioner table has paired 96365 as column 1 with the established-patient office visits 99212–99215 as column 2, modifier indicator 1 (the same edit, same effective date, pairs 96365 with the new-patient codes 99202–99205 and with 96360, 96372, 96374, 96413 and the rest of the 96360–96425 family). The infusion is assumed to include the minimal evaluation needed to give it — confirming the patient, the drug, the site and the rate — and an E/M billed alongside it denies as included unless the E/M line carries 25.
99211 is a harder edit, not a softer one. Per NCCI Policy Manual Chapter XI §B.8 (identical language repeats in §N.3 for the chemotherapy family): “The drug and chemotherapy administration CPT codes 96360-96379 and 96401-96425 have been valued to include the work and practice expenses of CPT code 99211 … CPT code 99211 is not reportable with chemotherapy and non-chemotherapy drug/substance administration HCPCS/CPT codes.” The 96365 / 99211 PTP edit carries modifier indicator 0 (in place since October 2020, same as 96360, 96372, 96374 and 96413 against 99211): no modifier unbundles it, because CMS has already priced the nurse-level check-in into the infusion code’s own valuation. A 99211 whose content is starting the line, watching for a reaction and disconnecting the pump is exactly that work — and it is the one E/M level an infusion visit can never separately bill, with or without 25.
Modifier 25 is a statement, and the note has to back it. A 99214 supports 25 when the record shows a problem addressed beyond the infusion: a new complaint worked up, a chronic condition adjusted, a medication changed, or the documentation elements for moderate-complexity medical decision making on something other than the drug being given. Checking that the patient tolerated last month’s dose before starting this one is not that; adjusting a blood-pressure medication at the same visit is. The claim builder above renders the infusion and the drug — the 96365 unit and 200 units of J1756 — and does not add the E/M, because whether the visit qualified is a documentation judgment the builder cannot make.
An E/M with its own reason is the test — content, not time or place: a problem evaluated or managed beyond the infusion, documented to the level billed. Modifier 25 asserts that; the note proves it. A 99211 can never clear this bar alongside an infusion — the edit bundles it regardless of documentation.
| Code | Descriptor | Practitioner MUE / day | Facility MUE / day | Adjudication · rationale |
|---|---|---|---|---|
99214 | office visit, established patient, moderate complexity | Outside the drug-and-administration MUE tables held here (E/M codes are not in scope). | ||
96365 | therapeutic/prophylactic/diagnostic IV infusion, initial hour | 1 | 2 | MAI 3 · Clinical: Data |
96365 is 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.
No drug-administration hierarchy rule is involved. The answer is the 96365 / 99214 procedure-to-procedure edit above, read together with NCCI Policy Manual Chapter XI §B.8: “The drug and chemotherapy administration CPT codes 96360-96379 and 96401-96425 have been valued to include the work and practice expenses of CPT code 99211 … Although CPT code 99211 is not reportable with chemotherapy and non-chemotherapy drug/substance administration HCPCS/CPT codes, other non-facility-based E&M CPT codes (e.g., 99202-99205, 99212-99215) are separately reportable with modifier 25 if the physician provides a significant and separately identifiable E&M service.”
CO-97 on the E/M line when a 99212–99215 is billed without 25 alongside 96365, or whenever 99211 is billed at all on an infusion date. If the record supports a separately identifiable evaluation, resubmit the 99212–99215 line with 25; a 99211 denial on an infusion day is not appealable — the work is already inside 96365’s valuation.
The median payer contract pays 120% of Medicare on 96365. 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. 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 |
1,762 payer×state medians for 96365 from 37 payers’ Transparency-in-Coverage files (2026-Q2-06); Medicare = national non-facility PFS.
This claim priced by your payer — Venofer’s rate on the drug line, 96365 at the payer’s contracted amount, the payer’s policy on Venofer (prior auth, covered diagnoses), and the patient’s share — is the same claim in your free account.
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On the E/M code. In the 96365 / 99214 PTP edit the E/M is the column-2 code, and 25 is an E/M-only modifier by definition — per NCCI Policy Manual Chapter I §E.b, the CPT Professional codebook defines it as a “Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service.” 96365 never carries 25.
No. NCCI Policy Manual Chapter XI §B.8 states plainly that 99211 is not reportable with drug/substance administration codes, because 96360-96379 and 96401-96425 are already valued to include that level of E/M work. The 96365 / 99211 PTP edit carries modifier indicator 0 — no modifier makes it separately payable. The claim is 96365 and the drug; the nurse’s check-in is inside the infusion code.
No. The evaluation needed to decide to proceed with the infusion — confirming tolerance of the last dose, checking labs drawn for that purpose — is part of 96365. An E/M with 25 requires a problem beyond the infusion — a new symptom, a change in another condition’s management — documented to the level of the code billed.
Yes. NCCI Policy Manual Chapter XI §N.3 repeats the identical 99211 language for the chemotherapy administration family (96401-96425), and the 96413 / 99211 PTP edit also carries modifier indicator 0, 96413 / 99212-99215 also indicator 1, both effective October 2020 — the same rule, the same dates, one family over.