Home infusion therapy — Medicare Plus Blue coverage and billing rules
Defines Medicare Plus Blue coverage, provider requirements, billing codes, and conditions for payment for home infusion therapy and related durable medical equipment, supplies, nursing, and drugs for Medicare Plus Blue members.
No material clinical or coverage changes in this revision.
Coverage Criteria
Enhanced home infusion therapy - general coverage
Covered when ALL of the following are met
Nursing visits
Nursing visits coverage rules
Billing interactions
Medicare alignment and Part D
Coverage scenarios
Coverage and billing scenarios (three scenarios) — follow the appropriate scenario based on which 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
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
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
| 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 |
Provider Actions & Billing Requirements
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 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.
- Original Medicare routing: follow Original Medicare coding and send claims per Original Medicare instructions.
- Medicare Plus Blue enhanced routing: use the enhanced benefit billing guidelines when Original Medicare criteria are not met.
- Drugs not covered by Original Medicare: report/submit to Part D or the member's prescription drug plan.
Documentation on file requirements
Before providing home infusion therapy services, providers must have on file a dated and signed physician order, certificate of medical necessity (CMN) or statement of medical necessity (SMN), and the physician's prescription. The physician order/CMN/SMN must include required patient and treatment details; nursing visits that are not authorized by the physician are not payable.
- Required on-file documents: dated and signed physician order, CMN or SMN, and physician prescription.
- Order/CMN/SMN must include: patient name, address, sex, birth date, diagnosis, dosage, infusion time, fluids, frequency, duration, route, equipment/supplies, and nursing orders (frequency of visits, flushes, central line changes, IV restarts, lab specimens/tests).
- Physician prescription must include: patient name, prescriber's signature and date, prescriber's printed name and address, drug name/strength, quantity, directions, refills, and any other federally/state-required information.
- Nursing visits not authorized by the physician are not payable.
Medical record retention and denial risk
The patient's medical record must reflect the need for the care provided and must be available to Medicare Plus Blue upon request. Failure to maintain medical records that document medical necessity, services provided, dates of service, physician orders/prescriptions, and required updates (e.g., physician updates at least every 30 days) may result in claim denials or retrospective denial of payment.
- Maintain clinical records that document medical necessity and support all billed services, supplies and nursing visits.
- Provide documentation of physician updates at least every 30 days (or more often if necessary) in the clinical record.
- Make records available to Medicare Plus Blue upon request to avoid denials.
Routing when Original Medicare criteria not met
When services do not meet Original Medicare coverage criteria, providers must route claims per the Medicare Plus Blue enhanced benefit or to the member's Part D/prescription drug plan as applicable. Follow the Medicare Plus Blue enhanced benefit billing guidelines (e.g., report DME/supplies/solutions on CMS‑1500, include per‑diem S codes with quantity/dates, report nursing and DME on the same claim where required).
- If Original Medicare criteria are not met and the member's plan includes the enhanced benefit, submit using the Medicare Plus Blue enhanced benefit billing instructions.
- DME, supplies and solutions: report date(s) of service, appropriate S procedure code, modifiers (SH/SJ) for concurrent therapies, and quantity equal to days infused.
- Nursing services: report CPT 99601 and 99602 (99602 on same day as 99601); follow limits and documentation requirements for additional visits.
Medical Necessity
DME coverage under enhanced benefit
DME and supplies covered as enhanced benefit when infusion therapy meets enhanced benefit criteria
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:
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 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.
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
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.
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