CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Home infusion therapy reimbursement and coding policy

Governs reimbursement, coding, documentation, and claim submission requirements for home infusion therapy services for Neighborhood Health Plan of Rhode Island members across Medicaid (excluding EFP), INTEGRITY, and Commercial lines.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHome infusion therapy reimbursement and coding policy

Policy CodePolicy N/A

Change TypeNew policy

Effective DateN/A

Next Review DateN/A

Key ActionVerify member eligibility, coverage and prior authorization requirements before providing home infusion services.

SourceLink

POLICY UPDATE CHANGES

New policy created

99601, 99602, G0088-G0090Key procedure and supply codes listed

Medicaid, INTEGRITY, CommercialLines of business this policy applies to

Fractional units deniedFractional units rule

~40HCPCS S-codes listed

11/28/2023Policy creation date

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria for Home Infusion Therapy

Coverage criteria for home infusion therapy

Coverage is provided when services are medically necessary and meet payer and referenced criteria.

All services must be medically necessary to qualify for reimbursement; Neighborhood may use NCD, LCD, Interqual, Rhode Island EOHHS recommendations, and Clinical Medical Policies (CMP) to determine medical necessity.

It is the provider's responsibility to verify eligibility, coverage and authorization criteria prior to rendering services; refer to Neighborhood's plan specific Prior Authorization Reference page and Clinical Medical Policies for details.

Covered medications are injectable, infused, or inhaled medications that are required for and an essential part of diagnosis and treatment and are received at home with drug administration services by a home infusion provider (examples include total parenteral nutrition therapy, chemotherapy, and antibiotics).

Coverage includes components required to administer these medications, including but not limited to durable medical equipment (DME), supplies, pharmacy compounding, and delivery of drugs and supplies.

Providers must submit complete claims within contractual timely filing guidelines and adhere to CPT, ICD-10-CM, and HCPCS coding standards; documentation may be requested and must support billed services and medical necessity per CMS standards.

Billing/exclusion rules

Usage notes and exclusions present in code descriptions

Do not use S9364 (TPN per diem) with S9365-S9368 (TPN daily volume scale codes).

Do not use S9373 (hydration per diem) with S9374-S9377 (hydration daily volume scale codes).

Do not use S9494 (home infusion antibiotic/antiviral/antifungal per diem) with hourly dosing codes S9497-S9504.

Do not use S9810 (professional pharmacy services per hour) with any per diem code.

Do not use S9372 (intermittent anticoagulant injection therapy) for flushing of infusion devices with heparin to maintain patency; S9372 is not intended for device flushing.

Billing Codes and Coding Rules

Listed covered codesmixedCovered

99601	Home infusion/specialty drug administration, per visit (up to 2 hours)
99602	Each additional hour (list separately)
G0088	Professional services, initial visit, for the administration of anti-infective, pain management, chelation, pulmonary hypertension, inotropic, or other intravenous infusion drug or biological (excluding chemotherapy or other highly complex drug or biological), each 15 min
G0090	Professional services, initial visit, for the administration of intravenous chemotherapy or other highly complex infusion drug or biological, each 15 min
B9002	Enteral nutrition infusion pump
B4164	Parenteral nutrition solution: carbohydrates (dextrose), 50% or less (500 ml = 1 unit), home mix
B4149	Enteral formula, blenderized, 100 calories = 1 unit
B9004	Parenteral nutrition infusion pump, portable
B9006	Parenteral nutrition infusion pump, stationary
B9998	NOC for enteral supplies

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Home infusion/home therapy S-codesHCPCSCovered

S5497	Home infusion therapy, catheter care/maintenance, NOC; includes administrative services, professional pharmacy services, care coordination, and necessary supplies and equipment, per diem
S5498	Home infusion therapy, catheter care/maintenance, simple (single lumen); includes administrative services, professional pharmacy services, care coordination and necessary supplies and equipment, per diem
S5501	Home infusion therapy, catheter care/maintenance, complex (more than one lumen); includes administrative services, professional pharmacy services, care coordination, and necessary supplies and equipment, per diem
S5502	Home infusion therapy, catheter care/maintenance, implanted access device; includes administrative services, professional pharmacy services, care coordination and necessary supplies and equipment (use for interim maintenance of vascular access not in use), per diem
S5517	Home infusion therapy, all supplies necessary for restoration of catheter patency or declotting
S5518	Home infusion therapy, all supplies necessary for catheter repair
S5520	Home infusion therapy, all supplies (including catheter) necessary for a PICC line insertion
S5521	Home infusion therapy, all supplies (including catheter) necessary for a midline catheter insertion
S5522	Home infusion therapy, insertion of PICC, nursing services only (no supplies or catheter included)
S5523	Home infusion therapy, insertion of midline venous catheter, nursing services only (no supplies or catheter included)

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Hourly rounding requirement

RuleIncremental codes must be used for any billed time that does not meet hourly rounding; hourly codes submitted with fractional units (e.g., 1.5, 2.5) will be denied.

RationaleCoding must meet CPT, ICD-10-CM, and HCPCS standards; fractional hourly units are not accepted by the plan.

Claim filing implicationSubmit separate incremental (non-hourly) codes for partial hours rather than fractional hour units to avoid denials.

Volume-based TPN/hydration coding rules

TPN volume-based codingUse daily volume scale codes S9365–S9368 for total parenteral nutrition (TPN) by liter-per-day increments; do not report S9364 together with S9365–S9368.

Provider Requirements and Billing Guidance

Prior Authorization

Prior Authorization Required

Verify member eligibility, benefits, and obtain plan-specific prior authorization when required. It is the provider's responsibility to confirm coverage and any authorization criteria before providing services. Refer to Neighborhood's Prior Authorization Reference page and applicable Clinical Medical Policies for details. Contact Provider Services at 1-800-963-1001 with questions.

Prior authorization required when indicated by plan benefit or Clinical Medical Policy.
Check member-specific limits, frequency, and site-of-service requirements prior to scheduling.
If services lack required prior authorization, claims may be denied or delayed.

Billing Rule

Billing and Coding Guidance

Definitions and Code Type Clarifications

Home infusion therapy

DefinitionHome infusion therapy involves the intravenous or subcutaneous administration of drugs or biologicals to an individual at home.

Services includedAdministrative services, professional pharmacy services, care coordination, supplies and equipment; drugs and nursing visits are coded separately according to code descriptions.

Typical therapy typesExamples include TPN, hydration, antibiotic/antiviral/antifungal, corticosteroid, enzyme replacement, insulin and other infusion/ injectable therapies administered in the home.

Per diem vs daily volume scale

Per diem codesCodes described as per diem (for example S9364 for TPN and S9373 for hydration) represent a single daily administrative/service rate for the episode and may include standard formula/supplies; drugs and nursing visits are coded separately.

Document Revision History

2023-11-28createdLatest

Policy created (new policy effective documentation).