(Medicare Claims Processing Manual)

180 - Billing for Home Infusion Therapy Services                                (Rev. 4112, Issued: 08- 10-18, Effective: 01 -01-19, Implementation: 01- 07-19) Effective January 1, 2019 and until the implementation of the full home infusion therapy benefit, Medicare makes separate temporary transitional payments for Home Infusion Therapy (HIT) services to eligible home infusion suppliers (i.e., a licensed pharmac y that provides external infusion pumps and external infusion pump supplies). This payment amount covers the cost of professional services, including nursing services, training and education (not otherwise paid for as durable medical equipment), remote monitoring, and monitoring services for the provision of home infusion therapy furnished by a qualified home infusion with administration of certain transitional home infusion drugs administered through an item of DME.   Temporary transitional payments are made for HIT services based on the home infusion drug provided.  Home infusion drugs are assigned to three payment categories, determined by the Healthcare Common Procedure Coding System (HCPCS) J -code.   Each DME MAC maintains a list of drugs that are administered through an item of DME and HIT payment is made for days  on which home infusion therapy services are furnished by skilled professionals in the individuals home on the day of infusion drug administration.  Temporary Transitional Payment Categories for Home Infusion Therapy Services, by Infusion Drug (J -Code)   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 J2274 Injection, morphine sulfate, preservative -free for epidural or intrathecal use, 10 mg J2278 Injection, ziconotide, 1 microgram  J3010 Injection, fentanyl citrate, 0.1 mg J3285 Injection, treprostinil, 1 mg Category 2  J-Code  Description  J1555 JB  Injection, immune globulin (cuvitru), 100 mg J1559 JB  Injection, immune globulin (hizentra), 100 mg  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 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 J9200 Injection, floxuridine, 500 mg J9360 Injection, vinblastine sulfate, 1 mg J9370 Injection, vincristine sulfate, 1 mg  The payment category for subsequent transitional home infusion drug additions to the Local Coverage Determinations (LCDs) and compounded infusion drugs not otherwise classified, as identified by HCPCS codes J7799 and J7999, will be determined by the DME MAC.  A single unit of payment will be made for HIT services provided in the individuals home during an infusion drug administration calendar day.   Suppliers will report the following HCPCS G -codes associated with the payment categories for the professional services furnished in the individuals home and on an infusion drug administration calendar day:   1. G0068: Professional services for the administration of anti -infective, pain management, chelation, pulmonary hypertension, and/or inotropic infusion drug(s) for each infusion drug administration calendar day in the individuals home, each 15 minutes.  Short Descriptor: Adm of infusion drug in home  2. G0069: Professional services for the administration of subcutaneous immunotherapy for each infusion drug administration calendar day in the individual's home, each 15 minutes. Short Descriptor: Adm of immune drug in home  3. G0070: Professional services for the administration of chemotherapy for each infusion drug administration calendar day in the individual's home, each 15 minutes.  Short Descriptor: Adm of chemo drug in home   In the event that multiple drugs, which are not all assigned to the same payment category, are administered on the same infusion drug administration calendar day, a single payment would be made that is equal to the highest payment category.    Providers should report visit length in 15- minute increments (15 minutes=1 unit).  See the table below for the rounding of units.  Rounding of Time Units   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   Claims that include G -codes for HIT services are not required to, but may also include the HCPCS J -code for the infusion drug, the E -code for the external infusion pump, and A-codes for supplies other than the drug.  A submitted claim for HIT services is subject to a Common Working File (CWF) edit in the event that a transitional drug J -code is not found on the same claim as the billed professional HIT services, or in claims history in the previous 30 days. If a J -code  is not found on the same claim as the billed professional services, the claims processing system will recycle the G -code claim for the professional services associated with the administration of the home infusion drug, until a claim containing the J -code for the infusion drug is received in the CWF. The professional visit claim will recycle three times (with a 30 -day look back period) for a total of 15 business days. After 15 business days, if no J -code claim is found in claims history, the G -code claim wi ll be denied.  Suppliers must ensure that the appropriate drug associated with the visit is billed with the visit or no more than 30 days prior to the visit.  Visits are denied if the appropriate drug for the visit is not billed.  In the event that multiple visits occur on the same date of service, suppliers must only bill for one visit and should report the highest paying visit with the applicable drug. Claims reporting multiple visits on the same line item date of service will be returned as unprocessable.    181  Lymphedema Compression Treatment Benefit  (Rev. 12379; Issued; 11- 22-23; Effective: 01 -01-24; Implementation:01- 02-24)  Effective for items furnished on or after January 1, 2024, section 4133 of the Consolidated Appropriations Act (CAA), 2023, establishes a new Medicare DMEPOS benefit category for standard and custom fitted compression garments and additional lymphedema com pression treatment items for the treatment of lymphedema that are prescribed by an authorized practitioner.   Claims for lymphedema treatment items that do not have an appropriate diagnosis for lymphedema will be denied. Claim payment can be made for lymphedema compression treatment items for more than one body part/area per beneficiary. In addition, claim payment  can be made for both a daytime and nighttime garment for the same body part/area per beneficiary.   A quantity of three daytime garments or wraps per body area and two nighttime garment per body area is allowed. Any amount billed that exceeds frequency limitations will be denied unless a replacement is needed due to a change in medical need or because a garment or wrap is lost, stolen, or irreparably damaged. Replacement of the garments can only be made in accordance with the proposed frequency limitation of once every 6 months for a daytime garment or wrap and once every two years for a nighttime garment . When billing for replacement of a garment or wrap use of the RA modifier is required. .  190 - A/B MAC (A), (B), or (HHH), or DME MAC  Application of Fee Schedule and Determination of Payments and Patient Liability for DME Claims (Rev. 1, 10- 01-03) A3-3629, B3- 5102   The following instructions apply to all A/B MACs (A), (B), and (HHH), and DME MACs processing DMEPOS claims:   First the 'allowable amount' is determined.  This is the lower of the fee schedule amount or the billed charge.   The application of deductible and coinsurance are calculated as follows.   A. Claims to A/B MACs (B) or DME MACs   Any unmet deductible is subtracted from the allowed amount and 80 percent of the remainder is paid.   B. Claims to A/B MACs (A) or (HHH)   NOTE:   Per 42 CFR 410.2 (Follow the link, choose the applicable year, select Title 42, then open Chapter IV.  You then must choose which part to open.  To get to 410.2 you select the second choice and open it, then select Part 410 and download the pdf version.), a nominal charge provider means a provider that furnishes services free of charge or at a nominal charge, and is either a public provider or another provi der that (1) demonstrates to CMS's satisfaction that a significant portion of its patients are low -income; and (2) requests that payment for its services be determined accordingly.   1. Payment to a Provider Other Than Nominal Charge Provider   To determine the Part B payment to a provider other than nominal charge provider, A/B MACs (A) and (HHH)  subtract any unmet Part B deductible from the lower of the actual charge or the fee schedule amount for the item or service and multiply the remainder by 80 percent.  This is the final payment.  (If the item or service is furnished by a HHA and is covered  under a plan of care, the payment is determined in the same way, except that no deductible is applicable.)   2. Payment to a Nominal Charge HHA   To determine the Part B payment to a nominal charge HHA, A/B MACs (HHH) subtract any unmet Part B deductible from the fee schedule amount and multiply the remainder by 80 percent.  This is the final payment.  (If the item or service is covered under a plan of care, the payment is determined in the same way, except that no deductible is applicable.)  For these items and services, no providers other than HHAs are considered nominal charge providers.   3. Payment to a Nominal Charge Provider Other Than a Nominal Charge HHA   To determine the Part B payment to a nominal charge provider other than a nominal charge HHA, A/B MACs (A) and (HHH)  subtract any unmet Part B deductible from the lower of the actual charge or the fee schedule amount and multiply the remainder by 80 percent.  This is the final payment.  4. Patient Liability to a HHA Other Than a Nominal Charge HHA   To determine the patient liability to a HHA other than a nominal charge HHA under Part B, A/B MACs (HHH) subtract any unmet deductible from the lower of the actual charge or fee schedule amount and multiply the remainder by 20 percent.  The result, plus the unmet deductible is the patient's liability.  If the item or service is covered under a plan of care, the deductible does not apply.  5. Patient Liability to a Nominal Charge HHA   To determine patient liability to a nominal charge HHA under Part B, A/B MACs (HHH) subtract any unmet deductible from the fee schedule amount and multiply the remainder by 20 percent.  The result, plus the unmet deductible is the patient's liability.  If the item or service is covered under a Plan of Care, the deductible does not apply.  6. Patient Liability to a Provider Other Than a HHA