CurrentMass General Brigham Health PlanPolicy N/A

Home infusion therapy reimbursement

Governs reimbursement and billing guidelines for medically necessary home infusion therapy provided by participating home infusion agencies to members of Mass General Brigham Health Plan, including coding, per-diem coverage, and documentation requirements.

Policy Summary

PayerMass General Brigham Health Plan

PolicyHome infusion therapy reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionEnter the authorization number in Form Locator 23 on CMS 1500 when submitting claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

per diemprimary payment method for home infusion services when drug infusion is administered same date

11-digit NDCNDC format required for billing; missing NDC with J-codes may deny

CMS 1500claim form required for home infusion billing

99601/99602Nursing visit billing codes for home infusion

JWRequired for billing drug wastage (single-use vial)

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Coverage and Billing Rules for Home Infusion

Coverage criteria and billing rules for home infusion

Covered when ALL of the following apply:

Home infusion therapy is reimbursed when medically necessary and administered in the member's home by a participating home infusion agency.

Reimbursement method: per-diem payment applies only on dates when a drug infusion is administered the same date.

Per-diem is primary payment method when infusion occurs same date.

Per-diem includes: initial patient assessment; professional pharmacy services and care coordination; infusion therapy–related supplies; teaching and related supplies/materials; delivery and removal of supplies and equipment; coordination of home care.

Per-diem excludes: drugs and biologicals; enteral formula administered via gravity/pump/bolus (oral formulas excepted); covered DME not related to infusion therapy (billed separately); nursing visits related to the infusion service; PICC and midline insertion kits; surgically implanted central venous access devices.

Reimbursement basis: payment is based on current Red Book AWP effective on date of service or provider contractual agreement; provider network/contract terms and payment edits may apply.

Member cost-sharing (copays, deductibles, coinsurance) applies per the member's benefit plan; providers must verify eligibility and benefit limitations.

Claims and documentation: claims must be submitted on CMS 1500 (or electronic equivalent) with the authorization number recorded in Form Locator 23 when applicable; itemize each date of service on separate claim lines.

All claims are subject to audit; services considered incidental, integral, mutually exclusive, or part of a global allowance are not eligible for separate reimbursement.

Home infusion billing criteria

Claims must meet ALL of the following billing and submission requirements:

Submit all home infusion claims on a CMS 1500 form or electronic equivalent; when multiple dates of service appear on one claim, itemize each date on a separate claim line (Form Locator 45).

Drug identification per service line: include the appropriate HCPCS code plus the 11-digit NDC, dosage administered that day, units administered, frequency, and duration of infusion when applicable. HCPCS 'J' codes submitted without an NDC may be denied.

NDC units and UOM: report the actual metric decimal quantity administered using the appropriate unit of measure code (ML, F2, GR, UN); use decimal notation for fractions (e.g., 1.5 ml).

Multiple-ingredient products: when a drug administered contains multiple ingredients, include each NDC on service lines and repeat the HCPCS code as necessary to represent each unique NDC.

Modifier and concurrent therapy guidance

Codes, Modifiers, and NDC Reporting

Representative CPT/HCPCS/S-codes for home infusion servicesmixedCovered

99601	Home infusion/specialty drug administration, per visit (up to 2 hours)
99602	Home infusion/specialty drug administration, each additional hour
S5498	Home Infusion Therapy, catheter care maintenance, simple (single lumen), per diem
S5501	Home Infusion Therapy, catheter care maintenance, complex (more than one lumen), per diem
S9330	Home Infusion Therapy, continuous chemotherapy infusion, per diem
S9365	Home Infusion Therapy, TPN, 1 per day, per diem liter
S9374	Home Infusion Therapy, hydration therapy 1 liter per per diem day
S9500	Home Infusion Therapy, antibiotic, antiviral or antifungal; once every 24 hours, per diem
S9558	Professional pharmacy services, care coordination, and all necessary supplies, equipment, per diem

Example billing codes and modifiersCPT | ModifierCovered

99601	Home nursing visit up to two hours
99602	Home nursing visit over two hours
JW	Drug amount discarded/not administered to any patient (wastage, single-use vials)

Modifier guidance for multi-drug and concurrent therapiesModifierCovered

KP	First drug of a multiple drug unit dose formulation
KQ	Second or subsequent drug of a multiple drug unit dose formulation
SH	Second concurrently administered infusion therapy
SJ	Third or more concurrently administered infusion therapy

inv-06: NDC unit reporting — expected units, UOM codes and format (decimal, metric)

Expected units to reportReport the actual metric decimal quantity administered (numeric quantity administered to the patient)

Accepted UOM codesF2 (International Unit); GR (Gram); ML (Milliliter); UN (Unit - each)

NDC units formatUse the actual decimal metric quantity (e.g., 1.5) when reporting fractions

inv-07: NDC units reporting — guidance on decimal notation for fractional units (e.g., 1.5 ml)

Fractional quantitiesReport fractional units using a decimal point (e.g., 1.5 ml)

Example

Provider Responsibilities and Claim Submission

Prior Authorization

Check referral and prior authorization requirements

Various services and procedures require referral and/or prior authorization. Referral and prior authorization requirements can be located on plan resources.

Documentation Required

Include authorization number on CMS 1500 (Form Locator 23)

When submitting claims on the CMS 1500 (or electronic equivalent), enter the authorization number in Form Locator 23; when multiple dates of service are on one claim, itemize each date on a separate claim line in Form Locator 45.

Terminology and Units of Measure

inv-10: Antibiotics — short definition

DefinitionA drug used to treat infections caused by bacteria and other microorganisms

ContextIncluded as a covered therapy type under home infusion services when medically necessary

ExamplesAntibiotics administered via infusion for bacterial infections

inv-11: Cancer Chemotherapy — short definition

DefinitionSystemic chemical treatment that targets and kills tumor cells; may be administered intravenously via catheter

Administration notePatients who require multiple rounds of IV chemotherapy may receive drugs through a catheter with an external or subcutaneous port

Policy Summary

PayerMass General Brigham Health Plan

PolicyHome infusion therapy reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionEnter the authorization number in Form Locator 23 on CMS 1500 when submitting claims.

SourceLink

On This Page

Use modifier KP for the first drug and KQ for the second or subsequent drug in a multiple drug unit dose formulation.

For concurrently administered infusion therapies, append SH for the second therapy and SJ for the third or subsequent therapy.

Home nursing services: bill nursing visits with CPT 99601 for visits up to two hours and CPT 99602 for visits over two hours; include additional units for extra hours as applicable.

Drug wastage: bill wastage from single-use vials on a separate claim line appended with modifier JW to identify unused/discarded drug; do not bill wastage when no drug was administered or for multi-use vials.

Paper claims: when submitting paper claims include KP/KQ modifiers as applicable for multiple drug formulations.

Denial risk and payment conditions: HCPCS 'J' codes submitted without an 11-digit NDC may be denied; claims payment is subject to member eligibility, benefits, prior authorization, utilization management, plan policies, claims edits, and provider contract terms.

If three 0.5 ml vials are dispensed, report a single quantity of 1.5 ml

PurposeDecimal notation ensures accurate billing of actual metric quantity administered

ScopeIncluded among therapies reimbursable under home infusion when medically necessary

inv-12: HCPCS 'J' Codes — definition and use

DefinitionHCPCS Level II 'J' Codes identify drugs administered by non-oral methods that cannot be self-administered (e.g., chemotherapy, immunosuppressives, inhalation solutions)

UseUsed on claims to report physician-administered or infusion drugs that are not self-administered

Billing implicationJ-codes submitted without an 11-digit NDC may be denied

inv-13: Per Diem — definition of per-diem payment for home infusion

DefinitionPer Diem: Payment for each day that a member is provided home infusion as prescribed by the physician

ApplicationPer-diem reimbursement applies when drug infusion is administered on the same date

IncludesMay encompass services such as assessment, pharmacy services, supplies, delivery/removal, and coordination when part of the per-diem

inv-14: NDC — definition and 11-digit format guidance

DefinitionNational Drug Code (NDC): an 11-digit universal product identifier for drugs in a 5-4-2 format

Formatting guidanceSome packages display fewer than 11 digits; leading zeroes must be assumed and used when billing to reach the 11-digit (5-4-2) format

PurposeIdentifies manufacturer (first 5 digits), product, and package size (remaining digits) for accurate drug reporting on claims

inv-15: TPN — Total Parenteral Nutrition definition

DefinitionTotal Parenteral Nutrition (TPN): Intravenous feeding that provides all fluids and essential nutrients when oral feeding is not possible

ContextTPN is listed among home infusion therapies reimbursable on a per-diem basis when appropriate

ExampleTPN may be billed using designated per-diem HCPCS/S-codes for home infusion

inv-16: F2 — Unit of measure code descriptor = International Unit

CodeF2

DescriptorInternational Unit

UseUsed as the unit-of-measure code when billing NDC quantities measured in international units

inv-17: GR — Unit of measure code descriptor = Gram

CodeGR

DescriptorGram

UseUsed as the unit-of-measure code when billing NDC quantities measured in grams

inv-18: ML — Unit of measure code descriptor = Milliliter

CodeML

DescriptorMilliliter

UseUsed as the unit-of-measure code when billing liquid drug quantities (milliliters) on claims

inv-19: UN — Unit of measure code descriptor = Unit (each)

CodeUN

DescriptorUnit (each)

UseUsed as the unit-of-measure code when billing discrete unit counts of a product