(Medicare Claims Processing Manual)

The Common Working File (CWF) shall create a new reject for claims with DOS on and after January 21, 2020, for claims received on or after October 5, 2020, to not allow payment for more than 20 acupuncture for cLBP claims per annum.  For acupuncture for cLBP claims CWF, FISS and the Multi -Carrier System (MCS) shall apply appropriate updates to the Next Eligibility Date file for DOS on or after January 21, 2020.   NOTE : Appropriate updates include modifications to HUQA, and Extract Records on the Next Generation Desktop (NGD) and the Medicare Beneficiary Database (MBD) for next eligible date and services remaining.   CWF shall count 11 full months starting with the month of a beneficiarys 1st acupuncture for cLBP service. EX: If 1st date of service is October 15, 2020, the next eligible date beginning a new year would be October 1, 2021.  NOTE: A new cLBP auxiliary (AUX) file will be created and HIMR will be updated to post the previous acupuncture for cLBP HCPCS 97810, 97811, 97813, 97814, 20560, or 20561.  For acupuncture for cLPB claims with DOS on and after January 21, 2020, the Multi -Carrier System Desktop Tool shall display the acupuncture for cLBP visits in a format equivalent to the CWF HIMR screen.    Effective for claims with DOS on and after January 21, 2020, received on and after October 5, 2020, CWF shall post acupuncture for cLBP HCPCS codes 97810, 97811, 97813, 97814, 20560, and 20561, reported on institutional claims, TOBs 12X, 13X, 71X, 77X, and 85X (and revenue code not equal to 096X, 097X, 098X), as the technical component on the new cLBP AUX  file.   NOTE: 1 TECH and 1 PROF on same DOS represents 1 service.   NOTE: CWF shall post the Part B Professional claim  line as TECH/PROF for the HCPCS if the modifier is blank.    CWF shall create a new reject for HCPCS 97810, 97811, 97813, 97814, 20560, and 20561 when a beneficiary has reached 20 acupuncture for cLBP sessions and the - KX modifier is not included on the claim line for sessions 13 through 20 (the reject will apply fo r both PROF and TECH sessions).  CWF shall update the determination when any changes occur to the beneficiary master data or claims data that would result in a change to the calculation   CWF shall create a new HICR function for the new cLBP AUX file.   411  Home Infusion Therapy Services  (Rev. 10269, Issued: 08- 07-2020, Effective: 01 -01-2021, Implementation: 01- 04-2021)  411.1  Policy  (Rev. 10269, Issued: 08- 07-2020, Effective: 01 -01-2021, Implementation: 01- 04-2021)  Effective beginning on January 1, 2021, the Medicare home infusion therapy benefit covers the professional services, including nursing services, furnished in accordance with the plan of care, patient training and education (not otherwise covered under the durable medical equipment benefit), remote monitoring, and monitoring services for the provision of home infusion therapy and home infusion drugs furnished by a qualified home infusion therapy supplier. Home infusion therapy means the items and services fu rnished by a qualified home infusion therapy supplier, which are furnished in the individuals home. Payment is for an infusion drug administration calendar day, which means the day on which home infusion therapy services are furnished by skilled profess ionals in the individuals home on the day of infusion drug administration. The skilled services provided on such day must be so inherently complex that they can only be safely and effectively performed by, or under the supervision of, professional or technical personnel.  411.2  Coverage Requirements  (Rev. 10269, Issued: 08- 07-2020, Effective: 01 -01-2021 Implementation: 01- 04-2021)   Payment for an infusion drug administration calendar day is only made if a beneficiary is furnished certain drugs and biologicals administered through an item of covered DME, and payable only to suppliers enrolled in Medicare as a qualified home infusion therapy supplier. The beneficiary must be under the care of an applicable provider, defined as a physician, nurse practitioner, or physicians assistant, and must be under the care of a physician- established plan of care that prescribes the type, amount , and duration of infusion therapy services. A qualified home infusion therapy supplier is a pharmacy, physician, or other provider of services or supplier licensed by the state in which supplies or services are furnished. Qualified home infusion therapy suppliers must furnish infusion therapy to individuals with acute or chronic conditions requiring administration of home infusion drugs; ensure the safe and effective provision and administration of home infusion therapy on a 7 -day-a-week, 24- hour-a-day basis; and be accredited by an organization designated by the Secretary. The supplier may subcontract with a pharmacy, physician, other qualified supplier or provider of services in order to meet these requirements.    411.3 - Home Infusion Drugs: Healthcare Common Procedural Coding System (HCPCS) Drug Codes (Rev. 11430; Issued: 05- 24-22; Effective: 07 -01-22; Implementation: 07 -05-22) The home infusion therapy services payment is intended to cover the professional services needed for  the administration of certain home infusion drugs covered as supplies necessary for the effective use  of external infusion pumps. This payment separately and explicitly pays for the services related to the  administration of the drugs identified on the DME LCD for External Infusion Pumps, when such services are furnished in the individuals home. Section 1861(iii)(3)(C) of the Act defines home  infusion drug as a parenteral drug or biological administered intravenously, or subcutaneously for an administration p eriod of 15 minutes or more, in the home of an individual through a pump that is an item of durable medical equipment (as defined in section 1861(n) of the Act). Such term does not  include insulin pump systems or self -administered drugs or biologicals on a self -administered drug exclusion list.   Home infusion drugs are assigned to three payment categories, as determined by the HCPCS J -code.  Payment category 1 includes certain intravenous antifungals and antivirals, uninterrupted long- term infusions, pain management, inotropic, chelation drugs. Payment category 2 includes subcutaneous  immunotherapy and other certain subcutaneous infusion drugs. Payment category 3 includes certain chemotherapy drugs. CMS will continue to use the G -codes, established for the temporary  transitional payments in CYs 2019 and 2020, for the professional services furnished on an infusion drug administration calendar day for each payment category. CMS has established a single payment  amount for each of the three categories for professional services furnished for each infusion drug administration calendar day. Each payment category will be paid at amounts in accordance with  infusion codes and units for such codes under the physician fee schedule for each infusion drug administration calendar day in the individuals home for drugs assigned to such category. The  payment amounts are equal to 5 hours of infusion therapy in a physicians office. Further policy information  can be found  in Publication 100- 02, Chapter  15, Section 320.   Category  1 J-Code  Description  J0133  Injection,  acyclovir,  5 mg J0285  Injection,  amphotericin  b, 50 mg J0287  Injection,  amphotericin  b lipid complex,  10 mg J0288  Injection,  amphotericin  b cholesteryl  sulfate  complex,  10 mg J0289  Injection,  amphotericin  b liposome,  10 mg J0895  Injection,  deferoxamine  mesylate,  500 mg J1170  Injection,  hydromorphone,  up to 4 mg J1250  Injection,  dobutamine  hydrochloride,  per 250 mg J1265  Injection,  dopamine  hcl, 40 mg J1325  Injection,  epoprostenol,  0.5 mg J1455  Injection,  foscarnet  sodium,  per 1000  mg J1457  Injection,  gallium  nitrate,  1 mg J1570  Injection,  ganciclovir  sodium,  500 mg J2175  Injection,  meperidine  hydrochloride,  per 100 mg J2260  Injection,  milrinone  lactate,  5 mg J2270  Injection,  morphine  sulfate,  up to 10 mg  J3010  Injection,  fentanyl citrate,  0.1 mg J3285  Injection,  treprostinil,  1 mg Category  2 J-Code  Description  J1551 JB  Injection, immune globulin (cutaquig), 100mg  J1555  JB Injection,  immune  globulin  (cuvitru),  100 mg J1558  JB Injection,  immune  globulin  (xembify),  100mg  J1559  JB Injection,  immune  globulin  (hizentra),  100mg  J1561  JB Injection,  immune  globulin,  (gamunex -c/gammaked),  non-lyophilized  (e.g. liquid),  500 mg J1562  JB Injection,  immune  globulin  (vivaglobin),  100 mg J1569  JB Injection,  immune  globulin,  (gammagard  liquid), non -lyophilized,  (e.g.,  liquid),  500 mg J1575  JB Injection,  immune  globulin/hyaluronidase,  (hyqvia),  100 mg immune  globulin  J7799  JB This NOC  code  may be used to identify  the subcutaneous  immune  globulin (cutaquig)  Category  3 J-Code  Description  J9000  Injection,  doxorubicin  hydrochloride,  10 mg J9039  Injection,  blinatumomab,  1 microgram  J9040  Injection,  bleomycin  sulfate,  15 units  J9065  Injection,  cladribine,  per 1  mg J9100  Injection,  cytarabine,  100 mg  J9190  Injection,  fluorouracil,  500 mg J9360  Injection,  vinblastine  sulfate,  1 mg J9370  Injection,  vincristine  sulfate,  1 mg  It is important to note that this list is not static. The payment category may be determined by the contractor  for any new home  infusion drug additions  to the Local  Coverage Determination  (LCD) for External Infusion Pumps as identified by the following not-otherwise- classified  (NOC)  codes :  - J7799 - Not otherwise classified  drugs, other than inhalation drugs, administered through DME   - J7999 - Compounded drug, not otherwise classified.  Attachment  A: Billing  for Home  Infusion  Therapy  Services  on or  After  January 1, 2021   Table 1 shows  the time increments  providers  should report  visit length in  15-minute  increments  (15 minutes  = 1 unit). See  the table  below  for the  rounding of units:   Table  1: Time  Increments   Unit Time  1 <23 minutes  2 = 23 minutes  to <38  minutes  3 = 38 minutes  to <53  minutes  4 = 53 minutes  to <68  minutes  5 = 68 minutes  to <83  minutes  6 = 83 minutes  to <98  minutes  7 = 98 minutes  to <113  minutes  8 = 113 minutes  to <128  minutes  9 = 128 minutes  to <143  minutes  10 = 143 minutes  to <158  minutes   Table 2 shows the  use of the  three G-codes  established  for the  home  infusion therapy  benefit,  and reflects the  therapy  type and complexity of the drug administration.   Table  2: Payment  Categories  for Home  Infusion  Therapy  Professional  Services  (G-Codes)    Category  1 Category  2 Category  3 Description