Key coverage rules and billing requirements extracted from policy text.
Per diem HCPCS codes for home infusion (examples include S9325-S9342 and other S-codes) cover administrative services, professional pharmacy services, care coordination, and necessary supplies and equipment and those included items are not separately reimbursable.
Certain TPN products are included in the TPN per diem and must not be billed separately (examples: non-specialty amino acids, concentrated dextrose, sterile water, standard multivitamin solutions, added trace elements).
Specific products are not included in the TPN per diem and may be billed separately (examples: specialty amino acids for renal or hepatic failure, specialty amino acids >=15% concentration, lipid products, added vitamins not from a standard multivitamin solution, non-nutritional products such as insulin, iron dextran, octreotide, ondansetron).
The per diem HCPCS code must be billed on the same claim as the corresponding drug for the same dates of service. Modifiers SH (second concurrently administered infusion) and SJ (third or more concurrently administered infusion) must be used when applicable.
Claims must include appropriate Place of Service codes (examples provided: POS 12 for home, POS 11 for office, POS 49 for home infusion suite).
Nursing services (evaluation, assessment, education, catheter insertion, training, consultation and home environment inspection) are reimbursed separately from the home infusion therapy per diem code.
When a cassette/reservoir is changed or refilled in a clinic, only the provider performing the service should bill; when changed/refilled in the home the applicable per diem HCPCS (e.g., S9328 for implanted pump management) should be billed.
Only one initial infusion service code may be reported per member encounter unless the protocol or member condition requires two separate IV sites; an additional IV access may be reported by appending the appropriate modifier to the initial service code.
Injectable therapies are payable only when billed with an approved medical IV therapy or when administration requires a registered nurse; self-administered therapies are not reimbursable except specified exceptions such as factor/hemophilia products.
The Plan may request supporting documentation to determine eligible reimbursement; claims should be supported by original medication orders, plan of care, pharmacy preparation notes, medication administration records, delivery/shipment information, and other documentation as requested.
Policy coding inclusions or code descriptions do not guarantee coverage; exclusions may apply under member benefit plans or provider contracts, and contract terms govern in the event of conflict.