Medical Policy Update

Prior Authorization Submission Reminder

BCBSWY is committed to improving communication and knowledge of medical policy updates. Effective 9/1/2024, BCBSWY will implement a new medical policy specific to Home Infusion services. Please review the below information for an overview of this policy.

Definition

Home infusion is the administration of medications or nutrition intravenously in a patient’s home, office, or a home infusion suite. Home infusion services must be ordered in writing by a physician.

Documentation must identify and describe the services performed including total time of the service. Appeals submitted without this documentation will be rejected.

Payment for HIT Services

The HCPCS “G” codes for home infusion services are to be used for billing. Billing for “G” codes includes professional services, including nursing services, furnished in accordance with care coordination, patient training and education, remote monitoring, and monitoring services for the provision of home infusion therapy.

Infusion pumps, home infusion drugs, other supplies, are to be billed separately. A G-code is billed for each day that a patient receives an infusion and services are rendered in person from the provider.

Home infusion therapy (HIT) is billed based upon type:

  • Intravenous infusion
  • Subcutaneous infusion
  • Intravenous chemotherapy or complex drug.

Billing for each code type is differentiated based upon “first visit” status. A visit is considered a first visit when it has been at least 60 days since a patient has received any home infusion therapy services billed with a G code.

All HIT services require at least one non-oral drug or biological to be billed alongside the G code. This drug determines the type mentioned above.

Code Description Visit Type
G0068 Administration of Intravenous infusion drug in home General Visit
G0069 Administration of Subcutaneous infusion drug in home
G0070 Administration of Intravenous chemotherapy or other complex drug in home
G0088 Administration of Intravenous infusion drug in home 1st Visit
G0089 Administration of Subcutaneous infusion drug in home
G0090 Administration of Intravenous chemotherapy or other complex drug in home

Services billed with G-codes will only be reimbursable when services are rendered in person in the patient’s home or in person at a home infusion suite. Provision of medications and remote support alone is not sufficient for a provider to be eligible for HIT reimbursement.

Other HIT Services with Different Guidelines from the Above

Enteral and Parenteral Nutrition Infusions

The HCPCS “S” codes for enteral and parenteral nutrition home infusion services are based on a “per diem” reimbursement methodology (S9341 – S9343, S9364 – S9368). The per diem includes all supplies, care coordination and professional pharmacy services. The per diem code is billed for each day that a patient receives an infusion, and services are rendered in person from the provider. Other nursing services and drug products are billed separately from the per diem.

Reimbursement is allowed separately for the following supplies: ambulatory infusion pumps (E0779-E0781). BCBSWY may allow separate reimbursement for other supplies on a case-by-case basis.

Per diems will only be reimbursable when services are rendered in person in the patient’s home or in person at a home infusion suite. Provision of medications and remote support alone is not sufficient for a provider to be eligible for per diem reimbursement.

Catheter Care

Bill catheter care per diems (S5497, S5498, S5501, S5502) when provided as a stand-alone therapy. Insertion by a nurse of a PICC line (S5522) or midline (S5523) is coded separately from the other nursing visit codes and per diems. Supplies required from non-routine catheter procedures such as de-clotting supplies (S5517), repair kits (S5518), PICC insertion supplies (S5520) and midline insertion supplies (S5521) are coded separately.

Hydration Therapy

Bill hydration therapy per diems (S9373-S9377) when provided as a stand-alone therapy.

Other Payments

Providers who do not render in-person infusions and are not eligible to be reimbursed a per diem or “G” code may still be eligible to be reimbursed for supplies as detailed below.

Medical Supplies

Medical supplies that are consumable, expendable, disposable, or non-durable and that are used for treatment of a patient’s specific illness, injury, may be reimbursed separately using the appropriate HCPCS code.

Drugs

Drugs should be billed with a HCPCS or CPT code. If a specific code is not available, providers should use J3490, J3590, J7799, or J9999 along with narrative, NDC number, dosage and units supplied. Related NDC codes for compounded products are itemized using the LIN and CTP segments on the 837P claim format. These claims may require manual review.

Multiple Therapies

If multiple therapies that would be billed using a per diem S code are done on the same date of service, append the following modifiers to the per diem S codes:

  • SH – Second concurrently administered infusion therapy
  • SJ – Third or more concurrently administered therapy

Only one G code is reimbursable each day. If two or more home infusion drugs or biologicals from two (or more) different payment categories are administered to an individual concurrently on a single infusion calendar day, one payment.

If both a service billed using a per diem and service billed using a G code are performed on the same day both codes should be submitted. Payment will only be made for the G code.

Claim Form

Home Infusion Therapy (HIT) providers should submit claims for services on HCFA 1500 or 837p.

Stay Informed: Register below for an upcoming prior authorization webinar to learn how BCBSWY will communicate new medical policies and updates beginning 7/1/24.


BCBSWY Prior Authorization Webinars

BCBSWY supported the recent legislation, HB0014 Ensuring Transparency in Prior Authorization Act, and worked with stakeholders to adopt policies intended to ease the administrative burdens for providers and members for prior authorization requests.

These upcoming webinars will help you become familiar with new processes to ease your prior authorization requests. We are offering two options that will cover the same content in both sessions.

Prior Authorization Enhancements Webinar

Wed., 6/12 12:00-1:00 pm

Register Now

Prior Authorization Enhancements Webinar

Tues., 6/18 12:00-1:00 pm

Register Now

Blue Cross Blue Shield of Wyoming will be closed on Monday, May 27 in observance of Memorial Day. Regular business hours will resume on Tuesday, May 28.

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