Reimbursement and billing criteria for infusion services, including home infusion per diem rules, documentation, modifiers, nursing, cassette/reservoir refill guidance, and place-of-service requirements.
Claims must be supported by appropriate documentation (medication orders, plan of care, administration records) and billed using valid HIPAA-approved codes.
Include appropriate Place of Service (POS) on claims: POS 12 for home, POS 11 for office, POS 49 for home infusion suite.
Per diem HCPCS codes (examples/ranges include S9490–S9590, S5497–S5523, S9325–S9379) encompass administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment; drugs and nursing may be coded separately where specified.
Per diem HCPCS must be billed on the same claim as the corresponding drug for the same dates of service.
When multiple concurrently administered infusion therapies are provided, append modifiers SH (second concurrently administered infusion therapy) and SJ (third or more concurrently administered infusion therapy) to the per diem HCPCS code as appropriate.
Only one initial infusion service code may be reported per member encounter per day unless the protocol or member's condition requires two separate IV sites; if a second IV site is reported, append the appropriate modifier to the initial service code.
Nursing services (evaluation/assessment, education, catheter insertion, training, consultation, home environment inspection, patient assessment) are reimbursed separately from home infusion per diem codes.
Cassette/reservoir change or refill: if performed in clinic, only the provider who performs the change/refill should bill (one claim for the service that day); if performed in the home setting, associated home infusion charges (medication, equipment, nursing services, per diem) should only be billed on the day the pump is changed/refilled and not billed continuously (e.g., do not bill daily for S9328 when change occurred once).
Certain components are separately reimbursable from the TPN per diem (non‑specialty amino acids, concentrated dextrose, sterile water, electrolytes, standard multi‑trace element solutions, standard multivitamin solutions, added trace elements).
Certain products are excluded from the TPN per diem and may be billed separately (specialty amino acids, lipids, added vitamins not from a standard MVI, and non‑nutritional products such as insulin, octreotide, ondansetron).
Per diem units equal the number of days therapy is provided regardless of dosing frequency within the day; examples include daily therapy = 1 unit/day, every 10 days over 30 days = 3 units, 3x/week for 2 weeks = 6 units.