Home Infusion Payment Policy Policy Blue Cross Blue Shield of Massachusetts (Blue Cross)* reimburses contracted providers for covered, medically necessary home infusion services. General Benefit Information Services and subsequent payment are based on the member s benefit plan and provider Agreement. Providers and their office staff may use our electronic technologies to verify effective dates and members copayments before initiating services. Please visit our etools page to access links that provide information on member eligibility and benefits. Member liability may include, but is not limited to copayments, deductibles, and/or co-insurance and will be applied depending upon the member s benefit plan. Certain services may require prior authorization or referral. Please refer to the member s subscriber certificate for more information and Authorization Requirements by Product. Home infusion services are managed as part of the member s home health care benefit. Payment Information Blue Cross reimburses health care providers based on: Network provider reimbursement or contracted rates Member benefits Claims are subject to payment edits, which Blue Cross updates regularly. Blue Cross reimburses: Compounding and supply per, depending on the drug therapy, which includes all medically necessary services, ancillary services and supplies, such as durable medical equipment (DME), administration supplies, diluents, educational materials, waste disposal, and pharmacy compounding fees Dispensed drugs and supplies that are not used due to unforeseen circumstances such as, emergency admission to hospital, physician order change, death not to exceed seven days. Infused or injected drugs Nursing per Parenteral nutritional solutions Blue Cross does not reimburse: Compounding and supply per when the drug is provided in the physician s office or facility Nursing per when the drug is provided in the physician s office or facility Billing Information Specific billing guidelines Home infusion therapy services and accompanying drugs and supplies should only be billed on a CMS-1500 form. The absence or presence of a procedure code or service does not imply or guarantee coverage or reimbursement. Code Service Description Comments 99601 Home infusion/specialty drug administration, per visit (up to 2 hours) 99602 Each additional hour Bill in conjunction with CPT 99601 S5035 Home infusion therapy, routine service of infusion device (example: pump maintenance) S5036 Home infusion therapy, repair of infusion device (example: pump repair) S5497 Home infusion therapy, catheter care and maintenance, not otherwise classified; includes administrative services, 1 of 6
S5498 Home infusion therapy, catheter care and maintenance, simple (single lumen), includes administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment, (drugs and nursing visits coded separately), per S5501 Home infusion therapy, catheter care and maintenance, complex (more than one lumen), includes administrative visits S5502 Home infusion therapy, catheter care and maintenance, implanted access device, includes administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment, (drugs and nursing visits (use this code for interim maintenance of vascular access not currently in use) 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 peripherally inserted central venous catheter (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) Home infusion therapy, insertion of midline venous catheter, S5523 S9325 S9326 S9327 S9328 S9329 S9330 nursing services only (no supplies or catheter included) Home infusion therapy, pain management infusion; coordination, and all necessary supplies and equipment, (drugs and nursing visits Home infusion therapy, continuous (twenty-four hours or more) pain management infusion; administrative services, professional pharmacy services, care coordination and all Home infusion therapy, intermittent (less than twenty-four hours) pain management infusion; administrative services, Home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy Home infusion therapy, chemotherapy infusion; administrative visits Home infusion therapy, continuous (twenty-four hours or more) chemotherapy infusion; administrative services, Do not use this code with S9326, S9327 or S9328 Do not use this code with S9330 or S9331 2 of 6
S9331 Home infusion therapy, intermittent (less than twenty-four hours) chemotherapy infusion; administrative services, S9336 Home infusion therapy, continuous anticoagulant infusion therapy (example: heparin), administrative services, professional pharmacy services, care coordination and all S9338 Home infusion therapy, immunotherapy, administrative visits S9345 Home infusion therapy, anti-hemophilic agent infusion therapy (example: factor viii); administrative services, professional supplies and equipment (drugs and nursing visits coded separately), per S9346 Home infusion therapy, alpha-1-proteinase inhibitor (example: prolastin); administrative services, professional pharmacy S9347 Home infusion therapy, uninterrupted, long-term, controlled rate intravenous or subcutaneous infusion therapy (example: epoprostenol); administrative services, professional pharmacy S9348 Home infusion therapy, sympathomimetic/inotropic agent infusion therapy (example: dobutamine); administrative all S9349 Home infusion therapy, tocolytic infusion therapy; and nursing visits S9351 Home infusion therapy, continuous or intermittent anti-emetic infusion therapy; administrative services, professional supplies and equipment (drugs and visits coded separately), per S9353 Home infusion therapy, continuous insulin infusion therapy; and nursing visits S9355 Home infusion therapy, chelation therapy; administrative visits S9357 Home infusion therapy, enzyme replacement intravenous therapy; (example: imiglucerase); administrative services, 3 of 6
S9359 Home infusion therapy, anti-tumor necrosis factor intravenous therapy; (example: infliximab); administrative services, S9361 Home infusion therapy, diuretic intravenous therapy; and nursing visits S9363 Home infusion therapy, anti-spasmodic therapy; administrative visits S9364 Home infusion therapy, total parenteral nutrition (TPN); coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits S9365 S9366 S9367 S9368 S9373 S9374 S9375 Home infusion therapy, total parenteral nutrition (TPN); one liter per day, administrative services, professional pharmacy equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits Home infusion therapy, total parenteral nutrition (TPN); more than one liter but no more than two liters per day, coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits Home infusion therapy, total parenteral nutrition (TPN); more than two liters but no more than three liters per day, coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits Home infusion therapy, total parenteral nutrition (TPN); more than three liters per day, administrative services, professional supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per Home infusion therapy, hydration therapy; administrative visits Home infusion therapy, hydration therapy; one liter per day, and nursing visits Home infusion therapy, hydration therapy; more than one liter but no more than two liters per day, administrative services, 4 of 6 Do not use with home infusion codes S9365-S9368 using daily volume scales Do not use with hydration therapy codes S9374-S9377 using daily volume scales
S9376 Home infusion therapy, hydration therapy; more than two liters but no more than three liters per day, administrative visits S9377 Home infusion therapy, hydration therapy; more than three liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies (drugs and nursing visits S9379 Home infusion therapy, infusion therapy, not otherwise classified; administrative services, professional pharmacy S9490 Home infusion therapy, corticosteroid infusion; administrative visits S9494 therapy; administrative services, professional pharmacy S9497 S9500 S9501 S9502 S9503 S9504 therapy; once every 3 hours; administrative services, therapy; once every 24 hours; administrative services, therapy; once every 12 hours; administrative services, therapy; once every 8 hours, administrative services, ; once every 6 hours; administrative services, professional supplies and equipment (drugs and nursing visits coded separately), per ; once every 4 hours; administrative services, professional supplies and equipment (drugs and nursing visits coded separately), per 5 of 6 Do not use this code with home infusion codes for hourly dosing schedules S9497-S950 When submitting claims for reimbursement, report all services with: Up-to-date industry-standard procedure and diagnosis codes Modifiers that affect payment in the first modifier field, followed by informational modifiers Related Policies
Medical policies Document History 12/01/2012 Documentation of existing policy 10/14/2014 Annual review, template update 09/02/2015 Annual review, template update 09/30/2016 Annual review; template update; inclusion of detailed documentation on existing policy and specific billing guidelines 09/30/2017 Annual review; addition of coding information and specific billing guidelines This document is designed for informational purposes only and is not an authorization, an explanation of benefits, or a contract. Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage. Medical technology is constantly changing, and we reserve the right to review and update our policies periodically. *Blue Cross refers to Blue Cross and Blue Shield of Massachusetts, Inc. and/or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. based on Product participation. 2017 Blue Cross and Blue Shield of Massachusetts, Inc. and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Registered marks of the Blue Cross Blue Shield Association. and SM Registered marks of Blue Cross Blue Shield of Massachusetts. and TM Registered marks of their respective companies. All rights reserved. Blue Cross and Blue Shield of Massachusetts, Inc. is an Independent Licensee of the Blue Cross and Blue Shield Association. Payment policies are intended to assist providers obtain Blue Cross Blue Shield of Massachusetts' payment information. Payment policy determines the rationale by which a submitted claim for service is processed and paid. Payment policy development takes into consideration a variety of factors including: the terms of the participating providers contract; scope of benefits included in a given member s benefit plan; clinical rationale, industrystandard procedure code edits, and industry-standard coding conventions MPC_071916-2H-1-PP (9/17) 6 of 6