CurrentBlue Cross Blue Shield - New MexicoPolicy CPCP019

Home Infusion

Defines billing, coding, documentation, and reimbursement rules for home infusion therapy provided to BCBSNM members; affects providers billing Blue Cross Blue Shield of New Mexico for home infusion services.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyHome Infusion

Policy CodePolicy CPCP019

Change TypeNo material change

Effective DateNovember 3, 2023

Next Review DateN/A

Key ActionObtain required prior authorizations and submit supporting documentation (medication orders, plan of care, pharmacy notes, administration records) with claims.

SourceLink

CPCP019policy identifier

2023-11-03plan effective date

per diemreimbursement basis

~60+sample codes listed

CPCP017, CPCP035related policies

Home Infusion Coverage and Billing Criteria

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Home infusion coverage and billing criteria

Reimbursement and billing criteria for home infusion and TPN per diem services

Claims must be billed with place of service 'Home' and per diem reimbursement applies only when a drug infusion is administered that day.

Per diem reimbursement includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (including DME, short peripheral vascular access devices, heparin and saline, solutions to dilute/reconstitute, and delivery).

Per diem HCPCS/S codes (home therapy and home infusion per diem codes) must be billed on the same claim as the corresponding drug for the same dates of service.

Certain per diem codes (S9537, S9542, S9558, S9559, S9560, S9562) are incidental to drug reimbursement and are not separately reimbursable.

Injectable therapies (SC/IM) are payable only when billed the same day as an approved IV therapy and/or when the injectable requires RN administration; self-administered therapies are not reimbursable except for factor/hemophilia products.

ALL of the following

Included in TPN per diem (not separately reimbursable): Non-specialty amino acids; concentrated dextrose (e.g., D10–D70); sterile water; electrolytes; 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 (renal/hepatic/high-stress formulations); specialty amino acids ≥15% when medically necessary for fluid-restricted patients; lipids; added vitamins not from standard multivitamin; non-nutritional products servicing other indications (e.g., insulin, iron dextran, ondansetron).

Units of service for per diem codes are counted per calendar day therapy is provided (examples: infusion every 4, 8, 12, or 24 hours for 7 days = 7 units; infusion once per week = 1 unit per week).

Per diem listing of numerous HCPCS/G/S codes describes categories of service (listing does not by itself constitute statement of coverage or reimbursement).

Claims and coding must follow HIPAA-approved code sets and standard coding guidelines; providers must maintain and submit supporting documentation (medication orders, plan of care, pharmacy prep notes, medication administration records, delivery/shipment information) upon request.

Inclusion and separate reimbursement rules

Supply and equipment codes listed are included in Home Infusion S-codes and are not eligible for separate reimbursement.

Supply and equipment HCPCS codes (e.g., A4206–A8004, A4300, A4301, A4305, A4306, A9900, A9999, E0776, E0779, E0780, E0781, E0782, E0783, E0784, E0785, E0786, E0791) are included in a Home Infusion S-code and should not be billed separately.

Note: A9270 is identified as a non-covered item.

IV solution codes (J7030–J7060) — separate billing is dependent on whether the solution is incidental to a drug infusion (e.g., keeping a line open) or is prescribed for a medical condition (e.g., hydration); billing should reflect concurrent use/medical necessity.

S9810 (professional pharmacy services billed hourly) should not be used with any per diem code; per diem codes include professional pharmacy services as part of the rate.

Home infusion visit codes 99601/99602 require a qualified healthcare professional to administer and have specific billing rules when used instead of per diem codes.

Authorization, Documentation, and Policy Application

Prior Authorization

Obtain prior authorizations and required administrative documentation

Obtain required administrative authorizations and supporting paperwork before or at time of service, including prior authorizations and certificates of medical necessity as applicable. Maintain verification of eligibility and other administrative tasks listed (coordination of benefits, licensure, patient financial services) to support claims.

Obtain prior authorizations when required.
Obtain certificates of medical necessity and other required documentation.
Verify insurance eligibility and coordinate benefits with other insurers.
Maintain licensure, regulatory compliance, and documentation storage.

Denial Risk

Resolve conflicts per plan/provider contract; expect BCBSNM discretion

Follow plan documents and provider contract terms when conflicts arise; BCBSNM may exercise reasonable discretion in interpreting and applying this policy where permitted by plan documents. Providers must code and document services per industry standard coding guidelines and applicable contract/plan requirements.

If policy conflicts with a plan document, the plan document governs; if conflict with a provider contract, the provider contract governs.
BCBSNM may use reasonable discretion in policy interpretation and application as allowed by plan documents.
Submit claims using HIPAA-approved code sets and industry standard coding guidelines.

Documentation Required

Maintain and provide supporting documentation on request

Retain and produce supporting documentation upon request; the plan reserves the right to request medical and billing records. Failure to adhere to coding and billing policies or to provide requested documentation may affect claim processing and reimbursement.

Be prepared to submit medication orders, plan of care, pharmacy preparation notes, medication administration records, delivery/shipment information, and certificates of medical necessity when requested.
Maintain maintenance and storage of medical and reimbursement records to support claims.

Key Definitions

inv-12: Drug

Drug definitionA drug is a substance recognized by an official pharmacopoeia or formulary intended for diagnosis, cure, mitigation, treatment, or prevention of disease; biological products are included.

Exclusions/notesCertain codes (J1642, A4216, A4218) are considered supply codes for home infusion and are not eligible for separate reimbursement; oral drugs, inhaled drugs, topical medications, and IDPN are not reimbursable when billed as home infusion services.

Intended effectIncludes substances intended to affect the structure or any function of the body and substances used as components of medicines (not devices).

inv-13: Home Setting

Home setting definitionIncludes the member's dwelling (house, apartment, private living space), a relative's home if the member lives there, other residences used as home, homes for the aged, retirement homes, and assisted living facilities; excludes skilled nursing facilities.

Place of service requirementClaims must be billed with the place of service 'Home' for per diem home infusion reimbursement to apply.

Determination of courseCourse and duration of therapy in the home setting are determined by the plan of care as prescribed by the ordering physician and documented appropriately.

inv-14: Per diem

Per diem meaningPer diem = each calendar day the member is provided access to prescribed therapy, beginning when therapy is initiated and ending when discontinued; course/duration per plan of care.

Per diem includesPer diem rates include administrative services, professional pharmacy services, care coordination, necessary supplies and equipment, and delivery as specified by the per diem code descriptions.

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

inv-15: Supplies and equipment included in Home Infusion S-codes

Included supply/equipment examplesTypical items included in Home Infusion S-codes: DME pumps and poles, infusion accessories, IV poles (E0776), short peripheral vascular access devices, needles, gauze, non-implanted sterile tubing, catheters, dressing kits.

Common HCPCS supply codes (not separately reimbursable)Examples listed include A4206–A8004, A4300, A4301, A4305, A4306, A9900, A9999, E0776, E0779, E0780, J7030–J7060 (IV solutions billing depends on incidental vs prescribed hydration).

Non-covered supply code noteA9270 is identified as a non-covered item or service and is included in the supply/equipment table.

inv-16: Home infusion visit HCPCS/CPT note

99601/99602 administration requirementBilling of 99601 (home infusion visit 2 hrs) and 99602 (each additional hour) requires a qualified healthcare professional to administer.

S9810 prohibition with per diemS9810 (hourly professional pharmacy services) must not be used with any per diem code.

Per diem vs hourlyPer diem codes describe comprehensive daily services (administrative, pharmacy, supplies); S9810 describes hourly services and is mutually exclusive with per diem codes.

OpenPayer

Home Infusion

Home Infusion Coverage and Billing Criteria

HCPCS, S-Codes, Modifiers, and Units

Authorization, Documentation, and Policy Application

Key Definitions