HOME INFUSION THERAPY QUICK REFERENCE GUIDE
Home Infusion Therapy: the administration of prescription drugs and solutions in the home via one of these routes:
- Intravenous • Intraspinal • Epidural • Subcutaneous
Per Diem: per day allowance for filing certain HCPC codes. Per diems are recognized by the number of hours the member receives the infusion and not by the calendar day. Continuous infusions for a period longer than 24 hours, but less than 48 hours are equal to one per diem.
Modifier 59 should be used to indicate conurrent infusion in conjunction with the SH or SJ, as appropriate.
Home infusion therapy requiring regular nursing services is to be billed in three components:
- Per Diem component (covering all home infusion services, equipment and supplies except the prescription drug and licensed nursing services) for each day the drug is infused.
- Nursing component provided by a Registered Nurse (RN) or Licensed Practical Nurse (LPN).
- Drug component Provider agrees to only bill for the quantity of drug actually administered not unused mixed, compounded or opened quantities. Provider agrees to bill only for those drugs referenced in the Fee Schedule.
NON-COVERED AND ALL INCLUSIVE SERVICES
The following services may not be billed under home infusion and are not part of your Home Infusion Therapy contract with BCBSNC:
- Oral prescription drugs (billed by pharmacy)
- Aerosolized drugs (billed by pharmacy)
- Services to hospice patients being cared for by a contracting hospice provider (billed by hospice)
- Durable medical equipment not directly related to the home infusion (billed by HDME provider)
- Drugs not reference in the Fee Schedule or that are not related, as determined by BCBSNC, to Home Infusion Therapy (billed by pharmacy)
- Antihemophilic Agents (Factor Drugs) are not considered valid Home Infusion Therapy drugs. Members can acquire these drugs through a participating Specialty Pharmacy vendor.
The following services are considered as included in the per diem rate and will not be reimbursed separately. The per diem rate includes all services not included in the pharmaceutical or nursing service component.
|• Durable Medical Equipment||• Solutions, Diluents and Flushes|
|• Care Coordination & Patient Education||• Administrative Services|
|• Professional Pharmacy Services||• Medical Supplies|
- Bill using the CMS-1500 claim form.
- Use your appropriate National Provider Identifier.
- File claims after services have been provided.
- Bill your typical retail charges for prescription drugs, infusion and nursing services.
- Miscellaneous codes are valid for use only if no suitable billing code is available and appropriate documentation is included.
The following list of codes has been determined as invalid services under the home infusion therapy specialty. Please note, effective December 15, 2009, these codes will no longer be reimbursable under the home infusion therapy benefit. Please note, this listing represents the top codes filed within the 2009 calendar year and is not considered to be an all-inclusive list.
|CODE||CODE DESCRIPTION||CODE TYPE|
|J7192||Factor VIII recombinant, per IU||Drug - Antihemophilic Agent|
|90378||Rsv ig, im, 50mg||Drug - Specialty Pharmacy|
|J7193||Factor IX non-recombinant, per IU||Drug - Antihemophilic Agent|
|J7195||Factor IX recombinant, per IU||Drug - Antihemophilic Agent|
|J7189||Factor VIIa recombinant, per 1 mcg||Drug - Antihemophilic Agent|
|J7187||Von Willebrand factor, injection||Drug - Antihemophilic Agent|
|J7190||Factor VIII human, per IU||Drug - Antihemophilic Agent|
|J1642||Injection heparin sodium per 10 units||Drug - Injection|
|Q4080||Iloprost, inhalation solution||Drug - Specialty Pharmacy|
|J1950||Leuprolide acetate /3.75 MG||Drug - Specialty Pharmacy|
|J7050||Normal saline solution infusion||Part of Home Infusion Therapy Per Diem|
|J3240||Thyrotropin injection||Drug - Specialty Pharmacy|
|J3490||Drugs unclassified injection||Misc Drug - No Description|
|J7322||Synvisc inj per dose||Drug - Injection|
|A4216||Sterile water/saline, 10 ml||Part of Home Infusion Therapy Per Diem|
|J7799||Non-inhalation drug for DME||Drug - DME|
|J8499||Oral prescrip drug non chemo||Drug - Oral|
|J2323||Natalizumab injection||Drug - Injection|
|J7321||Hyalgan/supartz inj per dose||Drug - Injection|
|J1595||Injection glatiramer acetate||Drug - Injection|
|J0585||Botulinum toxin a per unit||Drug - Specialty Pharmacy|
|J7324||Orthovisc inj per dose||Drug - Injection|
|J7030||Normal saline solution infusion||Part of Home Infusion Therapy Per Diem|
|J7323||Euflexxa inj per dose||Drug - Specialty Pharmacy|
|J2353||Octreotide injection, depot||Drug - Specialty Pharmacy|
|J1630||Haloperidol injection||Drug - Injection|
You can reference BCBSNC policies and procedures for Home Infusion Therapy in our Blue Book Provider Manual. Codes requiring Prior Plan Approval are on our website at www.bcbsnc.com (under the "Provider" section). Please check our website regularly for up to date information.
This Home Infusion Therapy Quick Reference Guide is not a guarantee of payment. As with all services, claims for Home Infusion Therapy are subject to your Agreement with BCBSNC; to BCBSNC's policies and procedures, including BCBSNC's medical policies; and to the terms of each member's contract. The service must be a covered service as a condition for payment. If there is a conflict between the Home Infusion Therapy Quick Reference Guide and your Agreement with BCBSNC or to BCBSN's policies and procedures, the Agreement and policies and procedures will prevail as indicated therein.