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Home Infusion Therapy - Help with Coding

  1. Question Home Infusion Therapy - Help with Coding
    Medical Coding Books
    Physician has his own pharmacy, sends medications home with patients.

    Uses the following codes:

    Home infusion therapy: S9500, S9501, S9502 (one of these 3 depending on the number of times the person infuses per day); they bill this code per diem
    Equipment and supplies: A4221, A4222, A4218, A4305
    Medication: J3370, J1642, J7040, J7050, J2405

    97535 - education/training

    96365 - infusion at initial visit in the office

    96374 - at initial visit

    What is the proper coding and place of service? Am I correct that if they bill for S9500 - S9502 this includes the supplies so they should bill either S9500-S9502 or the A codes along with the drugs.

    On another discussion post relating to home infusion, it was suggested that if the physician owns the pharmacy they should be billing the drugs as a dispensing pharmacy?

    Any guidance would be appreciated!

  2. #2
    Grand Rapids, MI
    Did you ever get any answer back on your question? If you are using S9500, how do you get it past Medicare to submit to the secondary insurance?

  3. #3
    You can't bill self-infusion services on a Medicare patient. Medicare doesn't cover self-infusions and they don't recognize S codes. There is a modifier you should be able to use that is basically telling Medicare to deny the claim so you can bill the secondary, but there is no way to get an S code processed in their system.

    As far as POS on the S codes, each carrier has its own rules. We bill S9500 - S9502 to Blue Cross with POS 12. All other insurances require that we use S9494 - if they accept an S code at all. United Healthcare doesn't accept either of the S code options. They swear they will, but if we use POS 11 they deny the claims as "invalid POS for the charge code" and if we use POS 12, they deny saying we're not certified home health providers and can't bill "home health." We don't provide home health services - we're a physician group that infuses IV antibiotics in the office or teaches the patient to self-infuse at home and then we supply the antibiotics.-- Cigna and Coventry require POS 12 with S9494. Other than that, we usually bill S9494 with POS 11. J codes are always billed with POS 11. We don't bill supplies separately - they're included in the S code.

  4. #4
    Grand Rapids, MI
    Thanks so much for getting back to me debkidcks. We have tried the GY modifier to get past medicare and aren't having any luck. Are you having any luck with another modifier? I know they won't pay for it, but we just want to get the denial to move on to the secondary insurance.

    The information regarding the other carriers is helpful as well. Thank you.

  5. #5
    We used the GY modifier, too. Modifier or no modifier, though, we just flat couldn't get the S code into Medicare's system for a denial. The electronic claims edits always kicked it out, and we don't qualify to send paper claims to Medicare so we can't even try that. We talked to Medicare and asked what to do, and they'd just say they couldn't tell us how to bill --

    Wish I had a solution. If you find out anything let me know!

    I'm curious - Have you tried billing 97535 for self-infusion teaching? The code description is under Physical Medicine and Rehab, and our teaching is done by nurses, which I can see being a problem with insurance carriers. I might run this by a provider rep and see what he/she says.
    Last edited by debkidcks; 03-06-2013 at 11:00 AM.

  6. #6
    Greetings All,
    We are billing under the Pharmacy (Not Physician). Should we be applying the EY modifier for these S codes, instead of a GY modifier?

    Also, I am not having any luck crosswalking B codes to S codes or S codes to B codes. Has anyone crosswalked these codes?

    Lastly, does anyone bill B codes to CMS? Any feedback is greatly appreciated!
    Evangelina Frohna, CPC, CEMC

  7. #7
    Default Home Self infusions
    My Physicians has started the infusion services. For commercial payers like BCBS and UHC patients mostly they call patient to office on first day and give supply for max of 6 days. In this case, I coded.

    Day 1 in office (pos - 11)- Jcode for drug
    96365 (initial hr
    96366 add time

    Day 2 - Day 7 self infusion (POS 12) - J code for each
    - Scode based on frequency (S9500 thru S9504)

    Do I need to bill 96365 or 97535 when pt is at home?

    Please advise the accuracy of my coding.


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