ModifiedNeighborhood Health Plan of Rhode IslandPolicy N/A

Home infusion therapy payment and reimbursement

Governs reimbursement and billing requirements for home infusion, enteral and parenteral nutrition, and related services for Neighborhood Health Plan of Rhode Island members across listed lines of business.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHome infusion therapy payment and reimbursement

Policy CodePolicy N/A

Change TypeAnnual reviewreimbursement statement added

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

Added statement to Reimbursement Requirements.

manycoding entries provided

parenteral & enteralcovered medication examples

deniedfractional units rule

tieredTPN/hydration tiers

presentpolicy history lines

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Coverage and Medical Necessity

Coverage criteria for home infusion services

Coverage is provided when ALL of the following are met:

ALL of the following

Neighborhood may use National Coverage Determinations (NCD), Local Coverage Determinations (LCD), InterQual, Rhode Island EOHHS recommendations, and Clinical Medical Policies (CMP) to determine medical necessity.

Medications are required for and an essential part of diagnosing or treating illness or injury.

Medications are received at home with drug administration services provided by a home infusion provider.

Covered medication types include (but are not limited to) total parenteral nutrition therapy, chemotherapy, and antibiotics administered at home.

Coverage includes components necessary to administer medications when medically necessary, including durable medical equipment (DME), supplies, pharmacy compounding, and delivery of drugs and supplies.

Simultaneous private nursing services and home infusion nursing oversight may be considered duplication/overlap; when duplication exists, coverage may be limited to the lowest level of care needed to safely meet the member's needs.

Documentation supporting the services billed and medical necessity is required; Neighborhood may request medical records to substantiate billed services.

Providers are responsible for verifying member eligibility, coverage, and prior authorization requirements prior to rendering services.

Claims must follow CPT/ICD-10/HCPCS coding standards and timely filing requirements; fractional hourly units on hourly codes will be denied.

Coverage coding constraints

Coding-based coverage and billing constraints

Per-diem codes cover administrative services, professional pharmacy services, care coordination, and necessary supplies and equipment; drugs and nursing visits are coded separately.

Do not bill S9810 (professional pharmacy services, per hour) with any per-diem code — per-hour and per-diem billing are mutually exclusive.

Hydration and TPN daily-volume codes are tiered by liters per day (e.g., S9374–S9377 for hydration; S9365–S9368 for TPN volumes) and should not be used concurrently with other hydration/TPN codes that use different daily volume scales.

S9372 (and similar codes intended for intermittent anticoagulant injections) must not be used for heparin flushing solely to maintain catheter patency.

Codes and Billing Guidance

sample infusion and management codesmixed

99601	Home infusion administration codes (per visit/time-based)
G0088	Professional services, initial visit; administration of anti-infective and other IV infusions in home (15 min increments)
S9325	Home infusion management infusion; administrative services, professional pharmacy services, care coordination, per diem (drugs and nursing visits coded separately)

enteral and parenteral nutrition codesHCPCS

B4150	Enteral formula, nutritionally complete, 100 calories = 1 unit
B4164	Parenteral nutrition solution: carbohydrates (dextrose), 500 ml = 1 unit, home mix
B4187	Omegaven, 10 g lipids

Home enteral nutritionHCPCSCovered

S9342	Home enteral nutrition via pump; per diem administrative services, professional pharmacy services, supplies and equipment (enteral formula and nursing visits billed separately)
S9343	Home enteral nutrition via bolus; per diem administrative services, professional pharmacy services, supplies and equipment (enteral formula and nursing visits billed separately)

Total parenteral nutrition (TPN)HCPCSCovered

S9364	Home infusion TPN; per diem including standard TPN formula (lipids, specialty amino acid formulas; drugs and nursing visits coded separately)
S9365	Home infusion TPN; one liter per day, per diem
S9366	Home infusion TPN; >1L to <=2L per day, per diem
S9367	Home infusion TPN; >2L to <=3L per day, per diem
S9368	Home infusion TPN; >3L per day, per diem

Hydration tiersHCPCSCovered

S9374	Home infusion hydration 1 liter per day, per diem
S9375	Home infusion hydration >1L to <=2L per day, per diem
S9376	Home infusion hydration >2L to <=3L per day, per diem
S9377	Home infusion hydration >3L per day, per diem

Per-hour professional pharmacy servicesHCPCSCovered

S9810

Home therapy; professional pharmacy services for infusion/specialty administration and/or disease state management; per hour (do not use with any per diem code)

inv-09: Hourly code rounding

Claim submission ruleIncremental codes must be used for time that does not meet hourly rounding requirements; hourly codes submitted with fractional units (1.5, 2.5, etc.) will be denied.

Coding standardsClaims must follow CPT, ICD-10-CM and HCPCS Level II coding standards as defined by respective code authorities.

Timely filingProviders must submit complete claims within contractually determined timely filing guidelines.

Provider Responsibilities and Billing Rules

Prior Authorization

Verify eligibility and prior authorization

It is the provider's responsibility to verify member eligibility, benefits, and any required prior authorization before rendering services. Confirm coverage and obtain prior authorization when applicable to avoid claim denials.

Verify member eligibility and benefit coverage prior to service.
Obtain and document prior authorization when required by Neighborhood Health Plan of Rhode Island.

Billing Rule

Billing rule — S9810 exclusivity

Do not bill HCPCS S9810 on the same claim with any per diem home infusion codes (S9372, S9373, S9374–S9377, S9379, S9490, S9494, S9497–S9504, S9562–S9563, S9590). S9810 describes professional pharmacy services for infusion/specialty administration per hour and is mutually exclusive with per diem codes. Billing both on the same date of service or same claim may result in denial or recovery of payment.

Key Terms

inv-14: Home infusion therapy

DefinitionHome infusion therapy: intravenous or subcutaneous administration of drugs or biologicals to an individual at home; includes components to administer medications such as DME, supplies, pharmacy compounding and delivery of drugs and supplies.

Covered servicesCoverage provided for injectable, infused or inhaled medications administered at home when medically necessary; examples include total parenteral nutrition, chemotherapy and antibiotics.

Included componentsCoverage includes administrative services, professional pharmacy services, care coordination, necessary supplies and equipment; drugs and nursing visits are coded separately when per diem codes are used.

Billing examplesMany home infusion services use per-diem HCPCS S-codes (e.g., S9342, S9364) or per-hour professional pharmacy code S9810 (S9810 must not be used with per-diem codes).

inv-15: Duplication/overlap of services

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHome infusion therapy payment and reimbursement

Policy CodePolicy N/A

Change TypeAnnual reviewreimbursement statement added

Effective DateN/A

Next Review DateN/A

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

SourceLink

On This Page

Affected code: S9810
Do not use with per diem codes: S9372, S9373, S9374, S9375, S9376, S9377, S9379, S9490, S9494, S9497–S9504, S9562, S9563, S9590

Billing Rule

Billing rule — S9372 exclusion

HCPCS code S9372 (home therapy; intermittent anticoagulant injection) is a per diem home therapy code and must not be reported in conjunction with infusion-specific per diem hydration or other per diem home infusion therapy codes for the same date of service. Do not bill S9372 with other per diem home infusion codes on the same claim/date.

Affected code: S9372
Do not combine S9372 with other per diem home infusion codes (see per diem list above) on the same date of service.

Billing Rule

Billing rule — Hydration code mutual exclusivity

Hydration codes S9374–S9377 are volume-based per diem hydration codes and are mutually exclusive with other per diem home infusion codes for the same date of service. Do not report hydration codes (S9374, S9375, S9376, S9377) together with other per diem infusion codes (including S9810 when used inconsistently with per diem billing) on the same claim/date. Use the appropriate single per diem hydration code that matches the daily hydration volume.

Affected codes: S9374, S9375, S9376, S9377
Use only one per diem hydration code per date of service corresponding to the total daily volume; do not report with other per diem infusion codes.

Duplication/overlap of services occurs when a member receives both private nursing services and home infusion nursing oversight concurrently.

Coverage effectWhen duplication or overlap is present, coverage may be limited to the lowest level of care necessary to safely meet the member's needs.

Provider responsibilityProviders should coordinate services and document the level of care required to justify billed services; records may be requested to support billed services.

inv-16: per diem

DefinitionPer diem therapy: HCPCS S-codes that cover administrative services, professional pharmacy services, care coordination, and necessary supplies and equipment on a per-day basis; drugs and nursing visits are coded separately.

TPN per-diem tiersTPN per-diem codes include S9364 (standard TPN per-diem) and daily volume tiers S9365–S9368 for 1.0L, >1–2L, >2–3L, and >3L per day respectively.

Hydration per-diem tiersHydration per-diem codes S9374–S9377 correspond to 1L, >1–2L, >2–3L, and >3L per day respectively; do not mix with other daily-volume scale codes.

inv-17: per hour

DefinitionPer-hour services: professional pharmacy services billed per hour using HCPCS S9810 for provision of infusion, specialty administration, and/or disease state management.

Mutual exclusivityDo not bill S9810 (per hour) with any per-diem code; per-hour and per-diem codes are mutually exclusive.

Fractional units ruleHourly codes submitted with fractional units (1.5, 2.5, etc.) will be denied; use incremental codes for time that does not meet hourly rounding requirements.