CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPO19

Home Infusion

Defines billing, documentation, coding and reimbursement rules for home infusion services provided to Blue Cross Blue Shield New Mexico members and expectations for provider submission of claims and supporting documentation.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyHome Infusion

Policy CodePolicy CPCPO19

Change TypeAnnual review (no material changes)

Effective DateNov 3, 2023

Next Review DateN/A

Key ActionProviders must submit accurate documentation and obtain prior authorizations and certificates of medical necessity as required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

per diemreimbursement basis

Place of Service = Homehome place of service

S93xx setS-code set

MultipleTPN tiers

Supply & equipment listbundled supplies

Coverage and Reimbursement Criteria

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Home infusion coverage criteria

Reimbursement and billing criteria for home infusion services:

Claims must be billed with place of service 'Home'.

Home infusion therapy is reimbursed on a per diem basis only when a drug infusion is administered.

The per diem covers administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment for effective administration of infusion, specialty drug and nutrition therapies.

Per‑diem HCPCS code must be billed on the same claim as the corresponding drug for the same dates of service.

When applicable, modifiers SH (second concurrently administered infusion therapy) and SJ (third or more concurrently administered infusion therapy) must be indicated with the HCPCS per‑diem code.

Injectable therapies (including subcutaneous or intramuscular) are payable only when billed on the same claim as an approved medical intravenous therapy and/or when administration requires a registered nurse; self‑administered therapies are not reimbursable except for factor/hemophilia products.

ALL of the following

Included in TPN per‑diem: sterile water; standard multi‑trace element solutions; standard multivitamin solutions; added trace elements from standard solutions.
Not included in TPN per‑diem (may be billed separately): specialty amino acids for renal/hepatic/high‑stress indications; specialty amino acids ≥15% when medically necessary for fluid‑restricted patients; lipids; added vitamins not from a standard multivitamin; non‑nutritional products (e.g., insulin, octreotide, iron dextran, ondansetron).

The Plan reserves the right to request supporting documentation; failure to adhere to coding and billing policies may impact claims processing and reimbursement.

Coverage stance for home infusion S-codes

Home infusion per diem S‑codes cover administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment; drugs and nursing visits are coded separately.

Home infusion S‑codes represent per‑diem payment for specified home infusion therapies and include pharmacy services, care coordination, and necessary supplies and equipment; drugs and nursing visits are coded separately.

Examples of per‑diem S‑codes

S9377 — Home infusion therapy, hydration therapy; more than three liters per day; per diem.
S9379 — Home infusion therapy, infusion therapy, not otherwise classified; per diem.
S9490 — Home infusion therapy, corticosteroid infusion; per diem.
S9494 — Home infusion therapy, antibiotic/antiviral/antifungal therapy; per diem (do not use with hourly dosing schedule codes S9497‑S9504).

Bundled supplies/equipment not separately reimbursable

Specific supply and equipment HCPCS codes are listed as components included in the S‑code per diem and are not eligible for separate reimbursement.

Supplies and equipment commonly included in the home infusion per‑diem (not separately reimbursable) include: DME (pumps, poles and accessories), equipment maintenance and repair (excluding member‑owned equipment), short peripheral vascular access devices, needles, gauze, non‑implanted sterile tubing, catheters, dressing kits, and other necessary supplies for effective administration.

Examples of HCPCS codes typically bundled into S‑codes (not separately reimbursable)

A4206, A4300‑A4306 — implantable/external access catheters, disposable drug delivery systems.
A9270 — miscellaneous DME supply/accessory (non‑covered item/service placeholder).
E0776, E0779‑E0786, E0791 — IV poles and ambulatory/parenteral infusion pumps (various types).

Codes, Units, and Volume Thresholds

Home infusion per-diem HCPCS (TPN and other therapies)HCPCSCovered

S9325	Home infusion therapy, pain mgmt infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, (drugs and nursing visits coded separately), per diem.
S9326	Home infusion therapy, continuous (24 hrs or more) pain mgmt infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, (drugs and nursing visits coded separately), per diem.
S9327	Home infusion therapy, intermittent (less than 24 hrs) pain mgmt infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment; (drugs and nursing visits coded separately) per diem.
S9328	Home infusion therapy, implanted pump pain mgmt infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment; (drugs and nursing visits coded separately) per diem.
S9329	Home infusion therapy, chemotherapy infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment; (drugs and nursing visits coded separately) per diem.
S9331	Home infusion therapy, intermittent (less than 24 hrs) chemotherapy infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment; (drugs and nursing visits coded separately) per diem.
S9340	Home infusion therapy, enteral nutrition, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment; (enteral formula and nursing visits coded separately) per diem.
S9364	Home infusion therapy, total parenteral nutrition (TPN); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment; including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem.
S9365	Home infusion therapy, total parenteral nutrition (TPN); one liter per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment; including standard TPN formula, per diem.
S9366	Home infusion therapy, total parenteral nutrition (TPN); more than one liter but no more than two liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment; including standard TPN formula, per diem.

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Home infusion S per-diem codes (other therapies)HCPCSCovered

S9335	Home infusion therapy, hemodialysis; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment; (drugs and nursing visits coded separately) per diem.
S9338	Home infusion therapy, immunotherapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment; (drugs and nursing visits coded separately), per diem.
S9339	Home infusion therapy, peritoneal dialysis; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment; (drugs and nursing visits coded separately), per diem.
S9341	Home infusion therapy, enteral nutrition via gravity; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment; (enteral formula and nursing visits coded separately) per diem.
S9342	Home infusion therapy, enteral nutrition via pump; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment; (enteral formula and nursing visits coded separately) per diem.
S9345	Home infusion therapy, anti-hemophilic agent infusion therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment; (drugs and nursing visits coded separately) per diem.
S9346	Home infusion therapy, alpha-1-proteinase inhibitor infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment; (drugs and nursing visits coded separately) per diem.
S9347	Home infusion therapy, uninterrupted, long-term, controlled rate IV or SC infusion therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment; (drugs and nursing visits coded separately) per diem.
S9348	Home infusion therapy, sympathomimetic/inotropic agent infusion therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment; (drugs and nursing visits coded separately) per diem.
S9349	Home infusion therapy, tocolytic infusion therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment; (drugs and nursing visits coded separately) per diem.

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TPN volume-based HCPCS S-codesHCPCSCovered

S9364	TPN per diem (standard formula) — use volume-specific S9365-S9368 when applicable.
S9365	TPN per diem — one liter per day.
S9366	TPN per diem — more than one liter up to two liters per day.
S9367	TPN per diem — more than two liters up to three liters per day.
S9368	TPN per diem — more than three liters per day.

Supply and equipment (bundled; not separately reimbursed)HCPCS

A4206	Medical and surgical supplies.
A4300	Implantable access catheter, external access.
A4301	Implantable access catheter, port/reservoir.
A4305	Disposable drug delivery system, flow rate of 50 mL or greater per hour.
A4306	Disposable drug delivery system, flow rate of less than 50 mL per hour.
A9270	Miscellaneous DME supply, accessory, and/or service — often used for items component to another HCPCS code (non-covered label).
E0776	IV pole.
E0779	Ambulatory infusion pump, mechanical, reusable, for infusion less than 8 hours.
E0780	Ambulatory infusion pump, single or multiple channels, electric or battery operated, with administration equipment worn by patient.
E0781	Infusion pump, implantable, non-programmable.

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inv-08: Units of Service examples

Units of Service examplesInfusion every 4 hours for 7 days = [calculate per 15-min increment]; Infusion every 8 hours for 7 days = [calculate per 15-min increment]; Infusion every 12 hours for 7 days = [calculate per 15-min increment]; Infusion every 24 hours for 7 days = 7 units; Infusion once per week = 1 unit (per week); Infusion once per month = 1 unit (per month)

inv-09: TPN volume thresholds

TPN volume thresholdsUse S9365 = 1 L/day; S9366 = >1–2 L/day; S9367 = >2–3 L/day; S9368 = >3 L/day. S9364 is the non-volume-specific TPN per diem (do not use S9364 with S9365–S9368).

Documentation, Prior Authorization, and Billing Responsibilities

Documentation Required

Documentation Requirements

Providers are responsible for submission of accurate documentation of services performed. Submit claims using valid HIPAA-approved code sets and code appropriately per industry standards (e.g., UB, AMA CPT, HCPCS, ICD-10-CM/PCS, NDC, DRG, CMS NCCI/CCI). Claims are subject to code edit protocols and review against benefit coverage, provider contract terms, medical policies, clinical payment and coding policies, and coding software logic. Upon request, the plan may require supporting documentation; providers are urged to submit any additional documentation to support medical necessity, coding, and billed services. Failure to adhere to coding and billing policies may impact claims processing and reimbursement.

Submit claims with accurate, complete documentation supporting the service, diagnosis, and medical necessity.
Respond to requests for additional documentation promptly to avoid claim denials or delays.
Maintain and make available medical and reimbursement records upon request (medical record retention and storage).

Documentation Required

Qualified Provider and Provider Responsibilities

Certain home infusion and supply/equipment codes require services to be performed or supervised by a qualified provider. The billing of 99601 and 99602 (home infusion visit codes) requires a qualified healthcare professional to administer. Providers must ensure appropriate licensure and qualifications when billing clinical visit or administration codes and must maintain documentation of the qualified provider who performed or supervised the service.

Qualified provider required for codes 99601, 99602 (home infusion visit codes).
Ensure licensure/accreditation as applicable (e.g., Joint Commission) and document provider qualifications and supervision.
When billing supply/equipment codes (e.g., E0779–E0791, J1642, J7030–J7060), retain documentation showing medical necessity and, where applicable, the qualified provider who ordered or supervised use.

Key Definitions

Drug

DefinitionDrug: A substance recognized by an official pharmacopoeia or formulary intended for diagnosis, cure, mitigation, treatment, or prevention of disease; biological products are included.

Exclusions/notesOral drugs (including oral nutrition), inhaled, topical medications, osteoarthritis drugs, and Intradialytic TPN (IDPN) are not reimbursable as home infusion services.

Supply-code exceptionJ1642, A4216 and A4218 are considered supply codes for home infusion services and are not eligible for separate reimbursement.

Home Setting

Home Setting definitionIncludes the member's dwelling (house, apartment or private living space), a relative's home where the member lives, a residence used as a home, and certain non‑SNF long‑term care residences (e.g., retirement home, assisted living).

Place of service requirementClaims must be billed with Place of Service = Home as required by the policy.

ExclusionDoes not include skilled nursing facility (SNF) as 'home setting'.

Per diem

Per diem definitionPer diem represents each day a member is provided access to a prescribed therapy from initiation through discontinuation as determined by the plan of care.

Per diem coverage scopePer diem payment covers administrative services, professional pharmacy services, care coordination, and necessary supplies/equipment; drugs and nursing visits are coded separately per policy.

Billing requirementThe per‑diem HCPCS code must be billed on the same claim as the corresponding drug for the same dates of service.

Supplies and equipment

Included itemsSupplies and equipment included in the Home Infusion S‑code per diem include DME (pumps, poles, accessories), IV poles, short peripheral vascular access devices, needles, gauze, non‑implanted sterile tubing, catheters, dressing kits, and other necessary supplies for infusion or nutrition administration.

Not separately reimbursableThe listed supply and equipment HCPCS codes are included in the S‑code per diem and are not eligible for separate reimbursement.

Examples of HCPCS codesExamples include A4206, A4300–A4306, A9270, E0776–E0791 and other commonly seen supply/equipment codes as listed in the policy.

Qualified healthcare professional

Qualified healthcare professional requirementBilling of home infusion visit codes 99601 (2 hours) and 99602 (each additional hour) requires a qualified healthcare professional to administer.

DocumentationThe plan may request supporting documentation; failure to adhere to coding/billing policies may impact claims processing and reimbursement.

Relation to visit hoursEach additional hour (99602) is listed separately in addition to the primary code and must be administered by a qualified healthcare professional.