Blue Cross Blue Shield MI home infusion therapy Coverage

Coverage Criteria

Enhanced home infusion therapy - general coverage

Covered when ALL of the following are met

Enhanced benefit general criteria: Prescribed by a physician within scope of practice to manage an incurable or chronic condition or treat a condition requiring acute care if it can be managed safely at home; certified by the physician as medically necessary; appropriate for use in the patient's home; is medical IV therapy, injectable therapy or total parenteral nutrition therapy.

Nursing visits

Nursing visits coverage rules

Nursing visits: Visits must correspond with therapy frequency and be documented with start and end times; requirement may be waived if experienced patient/caregiver declines and documentation includes physician order and statement that visits were explained and caregiver is capable and willing; waived when infusion services temporarily stopped and only catheter care needed.

Billing interactions

Catheter care payment: Catheter care is not payable when billed on the same day as medical IV therapy, TPN, injectable therapy or line insertion; if therapy temporarily suspended, one catheter care service payable per day.

Injectable therapy payment: Injectable therapy is payable only when billed on same day as an approved medical IV therapy.

Medicare alignment and Part D

Medicare consistency: Services, drugs, DME and supplies are covered consistent with Original Medicare coverage criteria; drugs not meeting Original Medicare criteria may be covered under the member's Part D or prescription drug plan; report drugs to the member's Part D plan when applicable.

Coverage scenarios

Coverage and billing scenarios (three scenarios) — follow the appropriate scenario based on which services meet Original Medicare coverage criteria

Scenario 1: All HIT services meet Original Medicare coverage criteria

Home health services and DME/supplies/drugs: follow Original Medicare coding; claim types UB-04 for home health and CMS-1500 for DME/supplies/drugs; send claims to local BCBS plan or BCBSM Medicare Plus Blue if DME jurisdiction applies

Scenario 2: Home health services meet Original Medicare criteria but DME, supplies or drugs do not

Home health: UB-04 to local BCBS plan following Original Medicare coding; DME/supplies: CMS-1500 following Medicare Plus Blue enhanced HIT benefit billing using per-diem S codes and send to local BCBS plan; drugs: follow member's Part D billing and send to Part D plan

Scenario 3: Home health services, DME, supplies and drugs do not meet Original Medicare criteria

Use CMS-1500; report nursing visits using CPT 99601 and 99602 and per-diem S codes for DME/supplies; report services on same claim and send claims to local BCBS plan; drugs billed to Part D

Coverage for home infusion drugs that do not meet Original Medicare coverage criteria is not provided under the Medicare Plus Blue enhanced home infusion therapy benefit. Such drugs may instead be covered under the member's Part D or prescription drug plan, and providers should route drug claims accordingly.

When a drug does not meet Original Medicare coverage criteria, submit the drug claim to the member's Part D or prescription drug plan. Medicare Plus Blue will apply enhanced home infusion therapy per‑diem coverage only when the service components meet the plan's enhanced benefit criteria consistent with Original Medicare alignment rules.

Nursing visits must be authorized by the physician and documented in the dated and signed physician order, CMN or SMN. Nursing visits that are not authorized by the physician are not payable.

Services that do not meet Original Medicare coverage criteria for home infusion therapy are not eligible under Original Medicare and must follow Medicare Plus Blue routing rules. When Original Medicare criteria are not met, providers should either submit drugs to the member's Part D or prescription drug plan or bill under the Medicare Plus Blue enhanced benefit using the applicable per‑diem S codes and billing procedures.

Coding and Billing Codes

DME and medical supplies (consistent with Original Medicare)HCPCSCovered

E0776
E0779
E0780
E0781
E0784
E0791
E1399
K0455
A4221
A4222

1–10 of 18

1/2

Drugs (consistent with Original Medicare)HCPCSCovered

J0133
J0285
J0287
J0288
J0289
J0895
J1170
J1250
J1265
J1325

1–10 of 35

1/4

Nutrients (consistent with Original Medicare)HCPCSCovered

B9004
B9006
B4164
B4168
B4172
B4176
B4178
B4180
B4185
B4189

1–10 of 20

1/2

Enhanced benefits DME, supplies and solutionsHCPCSCovered

S5497
S5498
S5501
S5502
S5517
S5518
S5520
S5521
S5522
S5523

1–10 of 56

1/6

Nursing services (enhanced benefits)CPT/HCPCSCovered

99601	Nursing services
99602	Nursing services

Covered/used procedure codesHCPCS | CPT

S9368	HCPCS S-code referenced
S9370	HCPCS S-code referenced
S9372	HCPCS S-code referenced
S9373	HCPCS S-code referenced
S9374	HCPCS S-code referenced
S9375	HCPCS S-code referenced
S9376	HCPCS S-code referenced
S9377	HCPCS S-code referenced
S9379	HIT, NOC, per diem
S9490	HCPCS S-code referenced

1–10 of 26

1/3

CMN duration

Maximum CMN duration120 days (CMN recertification required when CMN duration has expired)

Recertification contentRecertification must contain the same information as required on the initial physician order, CMN, or SMN

Triggers for new CMNNew CMN required if service discontinued and new initiated, patient hospitalized or admitted to nursing home, or CMN duration expired

Physician update frequency

Prescription renewalA new prescription is needed with a change in drug or therapy, and after 12 months even without a change

Provider Actions & Billing Requirements

Note

Coverage reporting/conditions

Certain DME, supplies, nursing services, and drugs are subject to coverage conditions consistent with Original Medicare. Report drugs to the member's Part D or prescription drug plan when they do not meet Original Medicare criteria. Follow Original Medicare coverage criteria where applicable; enhanced Medicare Plus Blue benefits apply when Original Medicare criteria are not met and the member's plan includes the enhanced benefit.

Enhanced benefits available when Original Medicare criteria are not met and the member's plan includes the enhanced Medicare Plus Blue home infusion therapy benefit.
Drugs that do not meet Original Medicare criteria should be submitted to the member's Part D or prescription drug plan.

Billing Rule

Billing and coverage routing

Services must meet Original Medicare coverage criteria to be billed and processed under Original Medicare routing. When services do not meet Original Medicare criteria and the member's Medicare Plus Blue plan includes the enhanced home infusion therapy benefit, submit claims under the Medicare Plus Blue enhanced benefit following the specific billing guidelines. If drugs are not covered under Original Medicare, submit to the member's Part D or prescription drug plan.

Medical Necessity

DME coverage under enhanced benefit

DME and supplies covered as enhanced benefit when infusion therapy meets enhanced benefit criteria

DME necessity: Durable medical equipment, medical supplies and solutions needed for home infusion therapy or parenteral nutrition are covered when infusion therapy is prescribed and certified as medically necessary and appropriate for home use.

Bundled per-diem includes DME and supplies not in pharmaceutical or nursing components.

DME payment criteria

When HIT is administered via external infusion pump or parenteral nutrition therapy consistent with Original Medicare coverage criteria:

Medicare-consistent HIT: Allowed amount consistent with Original Medicare when administered via external infusion pump or parenteral nutrition therapy and Original Medicare coverage criteria are met

When Original Medicare coverage criteria cannot be met, Medicare Plus Blue per-diem amounts apply

Rental and Purchase Rules

Item	Payment rule
Durable medical equipment, medical supplies and solutions for home infusion therapy (e.g., infusion supplies, solutions, diluents, flushes, administrative and professional pharmacy services, care coordination, patient education)	Bundled per‑diem (per‑diem rate includes all services not included in the pharmaceutical or nursing service component)
Services not included in pharmaceutical or nursing component (ancillary services related to home infusion)	Included in bundled per‑diem

Item	Payment rule
External infusion pump or parenteral nutrition equipment when home infusion therapy is administered via these modalities and Original Medicare coverage criteria are met	Allowed amount consistent with Original Medicare
External infusion pump or parenteral nutrition equipment when Original Medicare HIT coverage criteria cannot be met	Medicare Plus Blue allowed per‑diem amounts apply (capped rental equivalent handled via per‑diem)

Documentation Requirements

Documentation Required

Documentation required prior to providing services

Before initiating services, have on file a physician order, CMN or SMN and the physician prescription that include patient name and identifiers, diagnosis, drug name/strength, dosage, infusion details (frequency, duration, infusion time), equipment and supplies required, and nursing orders.

Billing Rule

Per‑diem S code dates and quantity requirements

Report per‑diem S procedure code dates of service to correspond with the beginning and end dates the patient received home infusion services; when reporting quantity, enter the total number of days the patient was infused for the therapy because S codes cannot be processed without a quantity.

Definitions

Home infusion therapy

DefinitionContinuous, slow administration of a controlled drug, nutrient, antibiotic or other fluid into a vein or other tissue on a daily, weekly or monthly basis

Therapy typesIncludes medical IV therapy, injectable therapy, and total parenteral nutrition therapy

Per-diem S codes

Per-diem S procedure codesUse HCPCS per-diem S codes (e.g., S9379) to report home infusion therapy per-diem services; include detailed documentation for S9379 describing service provided, route of administration, and drugs used

Associated HCPCS listProcedure codes referenced for HIT per-diem reporting include S9368, S9370, S9372–S9377, S9379, S9490, S9494, S9497, S9500–S9504, S9537, S9542, S9810

Billing guidanceWhen HIT criteria under Original Medicare cannot be met, Medicare Plus Blue allowed per-diem amounts will apply for S-code billing

Background

Home infusion therapy provides continuous or intermittent administration of drugs, nutrients, antibiotics, or other fluids in the patient's home for chronic or acute conditions that can be managed safely at home. The Medicare Plus Blue enhanced home infusion therapy benefit supplements Original Medicare and covers in‑home administration of infusion services when Original Medicare coverage criteria are not met, provided the therapy is prescribed by a physician, certified as medically necessary, appropriate for home use, and constitutes medical IV therapy, injectable therapy, or total parenteral nutrition therapy.

Not Covered

Home infusion drugs that do not meet Original Medicare coverage criteria are not covered under the Medicare Plus Blue enhanced home infusion therapy benefit. Providers should route such drugs to the member's Part D or prescription drug plan for coverage determination.

When services do not meet Original Medicare criteria for home infusion therapy and no Medicare Plus Blue enhanced benefit applies, the appropriate routing is to the member's Part D or prescription drug plan for drugs; other services should follow the Medicare Plus Blue enhanced benefit billing rules (for example, use per‑diem S codes where applicable) or be billed to the local BCBS plan per the policy's scenario guidance.

OpenPayer

Home infusion therapy — Medicare Plus Blue coverage and billing rules