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PAP243

Home IV Therapy Billing


Provider Administrative Policy

Section
Claims Submission
Policy Date
November 2007
Status/Date
Revised/August 2013
Provider Type(s)
All Providers  

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.

Policy

Home IV Therapy Billing

IV therapy services require prior authorization regardless of place of service. For authorization requests and requirements, please refer to PAP241. For hours of operation and contact information, please refer to PAP100.

When billing for home IV therapy, please submit claims on a CMS 1500 form with the following information populated. Blue Cross of Idaho can only apply correct benefits to prior authorized services if you submit the CMS 1500 in this manner. 

  • Diagnosis code(s)
    • Services must be billed with "from and through" dates in a span representative of the total episode of care. If the episode of care is greater than 7 days, bill for a minimum of 7 days per claim line with all charges associated with the Home IV episode on the same claim. To help avoid claim processing delays, the single claim should reflect all nursing services, therapy drugs, per diems, ancillary charges and any additional services that a Home IV provider would bill.
    • The first therapy billed may be considered your primary therapy and allowed at 100% of your fee schedule. Step down pricing may be applied to the second and subsequent concurrent per diem service(s). Indicate the secondary or subsequent therapy per diem service(s). Indicate the secondary or subsequent therapy per diem service(s). Indicate the secondary or subsequent therapy per diem service(s) with the appropriate modifier (SH or SJ).
    • Therapy drugs should be billed according to the following guidelines:
      • Therapy drugs shipped directly to the patient's home for self-administration should be billed with the "from and through" date as a one day span, which represents the date of shipment.
      • Therapy drugs shipped directly to the physician's office should be billed with the "from and through" date as a one day span, which represents the date of shipment.
      • Claims for Factor products should be billed with the "from and through" date as a one day span, which represents the date of shipment.
      • Therapy drugs billed with nursing administration, regardless of place of service, must be billed with "from and through" dates of the actual administration for a span of the episode of care. If the episode of care is greater than 7 days per claim line. You may not bill drug therapy codes with a ship date.
      • National Drug Codes (NDC) are required for all J codes.
      • A description, along with the NDC is required for J codes that do not provide an exact description of the drug. Please refer to PAP227 for additional information on unlisted and unclassified codes.

Blue Cross of Idaho will only consider benefits for services rendered by the home IV therapy provider. If the member discontinues therapy or receives treatment in a hospital, we will not allow concurrent benefits for IV therapy.

Codes should be specific for the type of service provided. If a code is invalid, we will return the claim to the provider for proper coding. Per diems must be the most appropriate and/or specific CPT for the services provided.

For drug waste requirement refer to PAP270.

Nursing Visits
If a home IV provider cannot provide nursing services, the home IV provider is required by contract to subcontract the nursing services to an independent nursing agency or hospital-based home nursing provider. This is specific for cases where home IV therapy is the primary reason for services. In those cases, the home IV provider agrees to bill Blue Cross of Idaho for the nursing services and reimburse the home healthcare agency directly. Blue Cross of Idaho does not accept individual home health care claims during a home IV therapy per diem authorization. Additional nursing visits require prior authorization and review. Providers are prohibited from billing for non-face to face services such as travel time, care coordination, or time spent completing documentation. All billed skilled services must be for direct face to face time with the member.

Nursing services are expected to be provided in an efficient manner and billed accordingly. Billing should occur for the time consistent with the expected infusion time. Billing for extended nursing time due to avoidable delays or staffing issues may not be reimbursable. Exceptions that are billed should be supported with justification in the documentation.

Home Infusion Therapy HCPCS


Policy History

Date Action Reason
April 2013 Revised Language revision
January 2010 Revised New Home IV contract

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