CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPO19

Home Infusion

Defines home infusion billing, coding, reimbursement (per diem) and documentation expectations for providers submitting claims to BCBSOK; affects providers delivering home infusion services to BCBSOK members.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyHome Infusion

Policy CodePolicy CPCPO19

Change TypeNo material changes

Effective DateJan 3, 2023

Next Review Date

Key ActionObtain prior authorization and maintain complete documentation (medication order, plan of care, pharmacy preparation notes, administration records) and submit upon request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

per diemreimbursement basis

Homeplace of service

Multipleper-diem codes

SH/SJconcurrent modifiers

Manyincluded supplies

Home Infusion Coverage and Billing Criteria

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Home Infusion Coverage and Billing Criteria

Rules for billing, reimbursement inclusions/exclusions, and required coding/modifiers.

Claims must be billed with Place of Service = Home.

Home infusion therapy is reimbursed on a per diem basis only when an actual drug infusion is administered that day.

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

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 as appropriate.

Per-diem rates include administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (examples: DME such as pumps/poles, heparin/saline, short peripheral access supplies, solutions used to dilute/reconstitute), and delivery required for effective administration.

Per-diem exclusions / incidental items

Per-diem codes S9537, S9542, S9558, S9559, S9560 and S9562 are incidental to drug reimbursement and are not separately reimbursable.
Certain TPN components are included in the TPN per diem and are not separately reimbursable (non-specialty amino acids, sterile water, standard multi-trace element solutions, added trace elements from standard solutions).
Other TPN-related products are not included in the TPN per diem and may be billed separately (specialty amino acids, lipids, added vitamins not from standard multivitamin solutions, and non-nutritional products such as insulin, iron dextran, octreotide, ondansetron).

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

Listing and defining HCPCS codes in this policy does not by itself constitute a statement of coverage or reimbursement.

Providers must maintain and make available upon request acceptable documentation, including medication orders, plan of care, pharmacy preparation notes, medication administration records, and delivery/shipment information.

Claims are subject to HIPAA-approved code sets, standard coding guidelines, code edit protocols and claim review; providers should submit additional documentation upon request.

Inclusion and documentation rules

Supplies and equipment policy

Certain supply and equipment HCPCS codes are considered included in a Home Infusion S-code per-diem and are not eligible for separate reimbursement.

Commonly included supplies and equipment typically encompass 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 supplies necessary for effective administration of infusion, specialty drug and nutrition therapies.

Billing of supply/equipment may depend on whether the item is incidental to a drug infusion or prescribed for a separate medical condition; the plan reserves the right to request supporting documentation and to review claims on a case-by-case basis.

Qualified provider requirement

Time-based home infusion visit coding

Billing CPT codes 99601 (home infusion visit, 2 hours) and 99602 (each additional hour) requires a qualified healthcare professional to administer the service.

HCPCS and Unit Coding for Home Infusion

Home infusion per diem HCPCSHCPCSCovered

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
S9330	Home infusion therapy, continuous (24 hrs or more) 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, per diem

Supply codes not separately reimbursableHCPCSNot Covered

J1642 / A4216 / A4218

Identified as supply codes for home infusion services and not eligible for separate reimbursement

Home infusion S-codes (per-diem)HCPCSCovered

S9353	Home infusion therapy, continuous insulin infusion therapy; administrative services, professional pharmacy services, care coordination, supplies and equipment; drugs and nursing visits coded separately; per diem
S9364	Home infusion therapy, total parenteral nutrition (TPN); administrative services, professional pharmacy services, care coordination, supplies and equipment; includes standard TPN formula; per diem (do not use with home infusion...)
S9374	Home infusion therapy, hydration therapy; one liter per day; administrative services, pharmacy services, care coordination, supplies and equipment; drugs and nursing visits coded separately; per diem

Supply and equipment codes commonly included in S-code per-diemHCPCSNot Covered

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
A4206	Medical and surgical supplies (example listed)

inv-08: Units of Service rule

Units definitionPer diem units correspond to each day a member receives an actual drug infusion; the per diem begins when therapy is initiated and ends when discontinued.

Example — every 4 hoursInfusion every 4 hours for 7 days = Units of Service 7.

Example — every 24 hoursInfusion every 24 hours for 7 days = Units of Service 7.

Example — weekly or monthlyInfusion once per week = 1 unit per week; infusion once per month = 1 unit per month.

Example — infrequent scheduleInfusion every 10 days for 30 days = Units of Service 3.

Prior Authorization, Documentation, and Billing Responsibilities

Prior Authorization

Prior Authorization and Administrative Responsibilities

Providers are expected to obtain any required prior authorization before delivering services and to maintain accurate administrative records. This includes verifying member eligibility and coverage, coordinating benefits with other insurers, obtaining certificates of medical necessity and other required documentation, and submitting claims using valid HIPAA-approved code sets. Upon request, providers should submit supporting documentation to the plan. Failure to adhere to coding and billing policies, or to provide requested documentation, may impact claims processing and reimbursement.

Coordination of benefits with other insurers
Verification of insurance eligibility and extent of coverage
Obtaining certificates of medical necessity and other required documentation
Obtaining prior authorizations
Patient financial services, billing, and account collection activities
Maintenance and storage of medical and reimbursement records

Documentation Required

Documentation and Review Rights

The plan reserves the right to request supporting documentation for billed services and supplies. Claims are subject to review against benefit terms, provider contract language, medical and clinical payment and coding policies, and claim-edit protocols. Providers are urged to submit additional documentation upon request; failure to comply may result in adverse claims decisions or reimbursement adjustments.

Claims subject to code edit protocols and claim review
Requests for additional documentation may be made on a case-by-case basis
Noncompliance with coding/billing policies may impact claims processing

Billing Rule

Qualified Provider Requirement for Time‑Based Home Infusion Visit Codes

Use of the time-based home infusion visit codes 99601 (home infusion visit — 2 hours) and 99602 (each additional hour) requires that a qualified healthcare professional administer the service. Bill 99601 as the primary time-based home infusion visit code and 99602 only for additional hours; do not report 99602 without the primary service. Ensure documentation supports the provider qualification, time units billed, and services rendered.

99601 — Home infusion visit (2 hours) — requires qualified healthcare professional to administer
99602 — Home infusion each additional hour — billed in addition to 99601, requires qualified healthcare professional

Key Definitions

inv-12: Drug

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

IncludesBiological products (noting manufacturing differences between chemical and biological processes).

Exclusions / not reimbursable as home infusionOral drugs, inhaled drugs, topical medications, certain osteoarthritis drugs, and Intradialytic TPN (IDPN) are not reimbursable when billed as home infusion services.

inv-13: Home Setting

What constitutes home settingThe member's dwelling (house, apartment) or other private living space, a relative's home if the member lives there, or a residence used as a home.

IncludesHomes for the aged, retirement homes, or assisted living facilities (does not include skilled nursing facilities).

inv-14: Per diem

Per diem definitionPer diem represents each day a member is provided access to a prescribed therapy, beginning when therapy is initiated and ending when therapy is discontinued; course and duration determined by the plan of care.

ApplicationPer diem reimbursement applies only when an actual drug infusion is administered that day.

DeterminationExpected course and duration are established by the ordering physician's plan of care and must be documented appropriately.

inv-15: Per-diem S-code

What is an S-code per-diemAn S-code per-diem is a home infusion HCPCS code that represents a daily (per calendar day) reimbursement rate covering administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment; drugs and nursing visits are coded separately.

Usage notePer-diem HCPCS codes (e.g., S9353, S9364, S9375, S9490, S9497, S9500) must be billed on the same claim as the corresponding drug for the same dates of service.

ScopeS-code per-diem descriptors include services such as continuous insulin infusion, TPN (standard formula), hydration therapy by liter thresholds, and various infusion regimens; do not use certain S-codes together where indicated.

inv-16: Included supplies/equipment

Included supplies and equipment (examples)Durable Medical Equipment for administration (pumps, poles, accessories) — includes equipment maintenance and repair (excluding member-owned equipment).

Common included itemsShort peripheral vascular access devices, needles, gauze, non-implanted sterile tubing, catheters, dressing kits and flushing kits.

Other included itemsSolutions used to dilute, reconstitute, or administer substances; heparin and saline; delivery for effective administration of infusion, specialty drug and nutrition therapies.

Reimbursement impactThese supplies and equipment are included in the S-code per-diem and are not eligible for separate reimbursement.