ModifiedBlue Cross Blue Shield - TexasPolicy CPCPO19

Infusion Services

Defines billing, coding, documentation, and reimbursement rules for infusion and home infusion services for providers submitting claims to Blue Cross Blue Shield of Texas.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyInfusion Services

Policy CodePolicy CPCPO19

Change TypeRevised (broader infusion scope) + Clarification

Effective DateJul 18, 2025

Next Review DateN/A

Key ActionObtain prior authorizations and certificates of medical necessity; submit supporting documentation upon request to determine eligible reimbursement.

SourceLink

POLICY UPDATE CHANGES

Policy revised to include broader scope of infusion services not limited to home setting; Policy title revised to support revisions; New definitions/terms added; Verbiage added for cassette/reservoir change/refill; POS codes, Nursing Services; Prescribed therapy UOS updated; Additional Resources and References updated.

Clarification added to: Reimbursement Information section, second paragraph; Cassette/Reservoir Change/Refill section.

Per diemreimbursement basis

12/11/49POS examples

TPN rulesTPN inclusions

~60+S-code count

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Infusion Service Coverage and Billing Rules

Infusion service reimbursement and billing criteria

Rules for reimbursement, billing, and included/excluded items for home infusion and related services.

Per diem HCPCS home infusion codes cover administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment; drugs and nursing visits may be coded separately where specified.

Claims must be billed with the appropriate Place of Service (POS) code (examples: POS 12 for home; POS 11 for office; POS 49 for a home infusion suite).

The per diem HCPCS code 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 used with the HCPCS code as appropriate.

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 requires administration by a registered nurse; self-administered therapies are not reimbursable except certain factor/hemophilia products.

TPN per diem includes non-specialty amino acids, sterile water, electrolytes, standard multi-trace element solutions, and standard multivitamin solutions; specialty amino acids, added non-standard vitamins, lipids, and non-nutritional products are excluded from the TPN per diem and may be billed separately.

Per diem units equal the number of days therapy is provided (examples include: infusion every 4, 8, 12, or 24 hours for 7 days = 7 units; infusion once per month = 1 unit); use the Plan's examples to calculate units of service for per diem coding.

Only one initial infusion service code may be reported per member encounter unless the protocol or the member's condition requires two separate IV sites; reporting a second site may be done by appending the appropriate modifier to the initial service code.

Nursing services (evaluation/assessment, education, catheter insertion, training, consultation, inspection of home environment) are reimbursed separately from the home infusion therapy per diem; when a cassette/reservoir is changed or refilled, only the provider who performs the change/refill should bill for that single service on that day.

The Plan reserves the right to request supporting documentation to determine eligible reimbursement; providers must submit documentation supporting billed codes and adhere to coding and billing policies; claims are subject to review and coding edits.

Home infusion coverage and billing rules

Supply and equipment reimbursement rules and exclusions for home infusion; items typically bundled with 'S' per diem codes and coding exclusions/constraints.

Supplies bundled with S-codes: Supply and equipment items (DME, pumps, poles and accessories, tubing, catheters, needles, dressings, IV poles, and related accessories), including equipment maintenance and repair (excluding member-owned equipment), are typically included in Home Infusion 'S' codes and are not eligible for separate reimbursement.

Code pair exclusions: Do not report certain code combinations together: do not use S9364 with the daily-volume scaled TPN codes S9365–S9368; do not use S9372 for heparin flushing to maintain catheter patency.

Hourly vs per diem coding: Do not use S9494 with hourly dosing schedule codes S9497–S9504. The per-hour code S9810 should not be reported with any per diem code.

Qualified professional requirement for CPT visit codes:

Codes, Units, and Coding Instructions

Home infusion per diem HCPCS codesHCPCSCovered

S9325	Home infusion therapy, management; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment
S9326	Home infusion therapy, continuous (24 hrs or more) management, per diem
S9327	Home infusion therapy, intermittent (less than 24 hrs) management, per diem
S9328	Home infusion therapy, implanted pump management, per diem
S9329	Home infusion therapy, chemotherapy infusion, per diem
S9330	Home infusion therapy, continuous chemotherapy infusion, per diem
S9331	Home infusion therapy, intermittent chemotherapy infusion, per diem
S9335	Home infusion therapy, hemodialysis, per diem
S9336	Home infusion therapy, continuous anticoagulant infusion therapy, per diem
S9338	Home infusion therapy, immunotherapy, per diem

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Professional infusion administration codesCPT | HCPCS

G0068	Professional services for administration of certain intravenous infusions in the individual's home, each 15 minutes
G0069	Professional services for administration of subcutaneous immunotherapy or other subcutaneous infusion in the home, each 15 minutes
60498	Chemotherapy administration; initiation using office/clinic pump with continuation in community setting

Home infusion 'S' codes and select related codesHCPCS

S9330	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 chemotherapy infusion; administrative services ... per diem
S9340	Home infusion therapy, enteral nutrition ... (enteral formula and nursing visits coded separately) per diem
S9347	Home infusion therapy, uninterrupted, long-term, controlled rate IV or subcutaneous infusion therapy ... per diem
S9364	Home infusion therapy, total parenteral nutrition (TPN); includes standard TPN formula ... per diem (do not use with S9365-S9368 using daily volume scales)
S9372	Home therapy, intermittent anticoagulant injection therapy (e.g., heparin); per diem (do not use for flushing of infusion devices with heparin to maintain patency)
S9494	Home infusion therapy, antibiotic, antiviral, or antifungal therapy; administrative services ... per diem (do not use with hourly dosing schedule codes S9497-S9504)
S9500	Home infusion therapy, antibiotic/antiviral/antifungal therapy; once every 24 hours; per diem
S9810	Home therapy; professional pharmacy services for provision of infusion, specialty drug administration, and/or disease state management; per hour (do not use with any per diem code)

Supply and equipment HCPCS/DME/J-codes (not separately reimbursable when included in S-codes)mixedNot Covered

A4300	Implantable access catheter, venous; external access
E0780	Ambulatory infusion pump, single or multiple channels, electric or battery operated, with administration equipment worn by patient
J1642	Injection, heparin sodium (heparin lock flush), per 10 units
A9270	Non-covered item or service / Miscellaneous DME supply

Per diem units calculation

Units definitionPer diem units equal the number of days the prescribed infusion therapy is provided (each calendar day of therapy counts as one unit).

Examples — frequent dosingInfusion every 4, 8, 12, or 24 hours for 7 days = 7 units (each day of therapy counts as one unit).

Examples — intermittent schedulesInfusion 3 times per week for 2 weeks = 6 units; infusion every 10 days for 30 days = 3 units.

Examples — low frequencyInfusion once per month = 1 unit per month.

Concurrent infusion modifiers

Provider Responsibilities and Documentation Requirements

Documentation Required

Documentation and claim review

Providers are responsible for submission of accurate documentation of services performed. Providers are expected to submit claims for services rendered using valid code combinations from HIPAA-approved code sets and to code appropriately according to industry-standard coding guidelines (e.g., UB, AMA CPT, HCPCS, ICD-10-CM/PCS, NDCs, DRG guidance, CMS NCCI edits). Claims are subject to review against plan documents, provider contract language, medical policies, clinical payment and coding policies, and coding software logic. Upon request, the provider must submit any additional supporting documentation to substantiate coding, medical necessity, and reimbursement. Failure to adhere to coding and billing policies or to provide requested documentation may impact claims processing and reimbursement.

Submit claims using valid HIPAA-approved code sets (CPT, HCPCS, ICD-10, etc.)
Respond to documentation requests promptly and supply supporting records to substantiate billed services
Claims are reviewed for benefit coverage, contract terms, medical/clinical policies, and code-edit logic

Defined Terms

Drug — definition and scope

DefinitionDrug: a substance recognized by an official pharmacopoeia or intended to affect body structure or function; includes biological products.

Supply codes considered non-drugsCertain supply codes (e.g., J1642, A4216, A4218) are treated as supply codes for home infusion and are not eligible for separate reimbursement as drugs.

Excluded administration routes/itemsOral drugs, inhaled drugs, topical medications, and certain therapies (e.g., Intradialytic TPN-IDPN) are not reimbursable when billed as home infusion services.

Home Setting

Qualifying locationsHome Setting includes the member's dwelling (house, apartment) or other private living space and a relative's home if the member lives there.

Included residences

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyInfusion Services

Policy CodePolicy CPCPO19

Change TypeRevised (broader infusion scope) + Clarification

Effective DateJul 18, 2025

Next Review DateN/A

Key ActionObtain prior authorizations and certificates of medical necessity; submit supporting documentation upon request to determine eligible reimbursement.

SourceLink

On This Page

Billing of CPT codes 99601 and 99602 for home infusion visits requires a qualified healthcare professional to administer the service.

Use modifier SH to indicate a second concurrently administered infusion therapy when billed with the per diem HCPCS code.

Modifier SJUse modifier SJ to indicate a third or more concurrently administered infusion therapies when billed with the per diem HCPCS code.

Billing requirementThe per diem HCPCS code must be billed on the same claim as the corresponding drug for the same dates of service when using concurrent infusion modifiers.

TPN volume-based coding instruction

Daily volume-scaled TPN codesWhen applicable, use the daily volume-scaled TPN per diem codes S9365–S9368 to report TPN based on liters per day.

S9364 restrictionDo not report S9364 (TPN per diem including standard formula) in conjunction with S9365–S9368 (daily volume-scaled TPN codes).

TPN code descriptionsS9365 = 1 L/day; S9366 = >1–2 L/day; S9367 = >2–3 L/day; S9368 = (higher volume category) — select code matching daily TPN volume.

Prior authorization and documentation requests

Obtain prior authorizations and any required certificates of medical necessity before providing services when plan coverage requires them. The Plan may request supporting documentation to determine eligibility for reimbursement; providers should be prepared to supply clinical records, orders, and other documentation upon request.

Obtain prior authorizations when required by the plan
Obtain certificates of medical necessity and other required documentation
Plan may request supporting documentation to determine eligible reimbursement

Billing Rule

Qualified professional requirement for home infusion visit CPT codes

Billing of CPT codes 99601 (Home infusion visit — first 2 hours) and 99602 (Home infusion — each additional hour) requires that a qualified healthcare professional administer the service. Ensure the provider performing and billing these services meets the plan's qualified professional requirements and that the documentation supports the billed home-infusion time and place of service.

CPT 99601 — Home infusion visit (first 2 hours)
CPT 99602 — Home infusion each additional hour (List separately in addition to primary code)
Ensure qualified healthcare professional administers and documents the service; use appropriate Place of Service (e.g., POS 12 for home)

Places of residence used as home or place of dwelling are considered home settings for billing purposes.

ExclusionsSkilled nursing facilities are explicitly excluded from the Home Setting definition.

Home Infusion Therapy

ScopeHome Infusion Therapy involves intravenous or subcutaneous administration of drugs or biologicals to an individual at home.

Core componentsRequired components include the drug, equipment, and supplies necessary to perform the infusion.

Care processesNurses typically train patients/caregivers to self-administer, educate on side effects and goals of therapy, and provide periodic site assessment and dressing changes; coordination among multiple entities is typical.

Per diem

DefinitionPer diem represents each day a member is provided prescribed therapy, beginning when therapy is initiated and ending when discontinued.

Determination of courseThe expected course and duration of treatment is determined by the plan of care prescribed by the ordering physician and must be documented.

Unit countingPer diem counting is calendar day–based; each day therapy is provided equals one per diem unit.

Included supplies and equipment

Typical bundled itemsPumps and accessories for nutrition administration, IV tubing, short peripheral vascular access devices, needles, gauze, and catheters are commonly included with Home Infusion 'S' codes.

Additional bundled suppliesDressing kits and other necessary supplies for safe and effective administration of infusion, specialty drug(s), and nutrition therapies are included in S-codes.

Maintenance/repairEquipment maintenance and repair (excluding member-owned equipment) are typically considered bundled and not separately reimbursable.

Qualified healthcare professional requirement

Qualified professional requirementBilling CPT codes 99601 and 99602 requires a qualified healthcare professional to administer the home infusion visit and any additional hours billed.

Code use99601 = home infusion visit (2 hours); 99602 = each additional hour (list separately in addition to primary code).

Documentation expectationServices billed with these CPT codes should reflect administration performed by the qualified healthcare professional as required by the policy.