RETIRED - Frequently Asked Questions - Temporary Transitional Payment for Home Infusion Therapy Services for CY 2019 and 2020 (CR10836) - JA DME

Joint DME MAC Publication

Background: Effective for dates of service (DOS) on or after January 1, 2019, the following G-codes are available for billing certain home infusion therapy services:

The following FAQs address some of the questions received by the DME MACs.

1. Contrary to the Final Rule I am being told by CMS that Home Health Agencies (HHA) can qualify beneficiaries for episodes of care based on their infusion needs. If an HHA is providing the home infusion nursing services under an Episode of Care, can the Home Infusion supplier bill for Home Infusion professional services (that includes pharmacy services)?
   
   Response: Section 50401 of the Bipartisan Budget Act of 2018 (Pub. L 115-123) amended Section 1834(u) of the Social Security Act (the Act) by adding paragraph (7), which requires a temporary, transitional payment be made to eligible home infusion suppliers for home infusion therapy services furnished on or after January 1, 2019 until the implementation of the full home infusion therapy benefit, as required by section 5012(d) of the 21st Century Cures Act (Pub. L. 144-255).
   
   Section 1842(u)(7)(F) of the Act requires eligible home infusion suppliers to be Medicare DME suppliers that are enrolled as pharmacies that supply external infusion pumps and supplies in order to receive the home infusion therapy services temporary transitional payment. Not until the full implementation of the benefit in 2021 will home health agencies have the option of becoming home infusion therapy suppliers.
   
   56406 Federal Register / Vol. 83, No. 219 / Tuesday, November 13, 2018 / Rules and Regulations, states: "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." [Emphasis Added]
   
   § 486.520(a), requires that all patients must be under the care of an ‘‘applicable provider'' as defined at § 486.505. Section 486.520(b) requires that the qualified home infusion therapy supplier ensure that all patients must have a Plan of Care established by a physician that prescribes the type, amount, and duration of home infusion therapy services that are furnished. The Plan of Care would also include the specific medication, the prescribed dosage and frequency as well as the professional services to be utilized for treatment. In addition, the plan of care would specify the care and services necessary to meet the patient-specific needs.
   
   Section 5012 of the 21st Century Cures Act added section 1861(iii)(3)(D)(i) to the Act that defines the term qualified home infusion therapy supplier as a ‘‘pharmacy, physician, or other provider of services or supplier licensed by the State in which the pharmacy, physician, or provider or services or supplier furnishes items or services and that . . . . ‘‘(III) is accredited by an organization designated by the Secretary pursuant to section 1834(u)(5) . . .'' [Emphasis Added]
   
   Medicare Claims Processing Manual Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §180, defines "eligible home infusion suppliers" as: "a licensed pharmacy that provides external infusion pumps and external infusion pump supplies)." [Emphasis Added]
   
   It is important to emphasize that the home infusion therapy services temporary transitional payment is separate from the home health benefit. Home infusion therapy is excluded from the Medicare home health benefit, and separately payable, beginning January 1, 2019. As a result of the benefit restrictions, HHAs can neither "qualify" beneficiaries, nor render services and bill under this benefit, since they are not "eligible home infusion suppliers". CMS recognizes that currently home infusion suppliers may contract with HHAs to furnish the nursing services; however, it is incumbent upon the home infusion supplier to negotiate appropriate contract terms in order to only assume responsibility for services related to home infusion therapy.
    
2. If billing for Home Infusion Professional Services depends on whether or not a Home Health Episode of Care is in place, how can a Home Infusion Supplier ascertain if a beneficiary is currently under an HHA Episode of Care?
   
   Response: The supplier should use standard Medicare procedures to check if a beneficiary is under a HHA Episode of Care:
   1. Contractor Medicare Portal
   2. IVR
   3. Check with beneficiary
3. If the beneficiary is under a HHA Episode of Care and the HHA does not have staff with IV skills available to manage the infusion-related nursing care, can the home infusion provider bill the Home Infusion Professional Services?
   
   Response: Please see response to Question 1 above – Payment can only be made to "eligible home infusion suppliers" – and thus, even if capable of managing infusion-related nursing services, the HHAs cannot bill for the G-codes since they are not deemed by CMS to be an "eligible home infusion supplier".
   
   Eligible home infusion suppliers are reminded to review Medicare consolidated payment rules prior to providing services and billing for the G-codes for beneficiaries under a HHA Episode of Care.
    
4. Please provide examples of billing units (15 minutes increments). Does the number of units affect the total payment amount or is it a fixed amount per calendar day regardless of the number of units?
   
   Response: CR 10836 states: "Providers should report visit length in 15-minute increments (15 minutes=1unit)." CR 10836 provides the following table for time increments:
   
   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

   
   
   CR 10836 goes on to state: "The fees associated with the G codes on the DMEPOS fee file will be ‘a per day rate;' therefore, the units on the line should not be multiplied by the rate." [Emphasis Added]
   
   Thus, the payment amount is a fixed amount per day regardless of the number of units.
    
5. The Medicare Learning Network (MLN) article accompanying CR10836 states that only one home infusion therapy services G-code will be reimbursed for each calendar day. How do we deal with multiple providers of covered infused drugs? Is it whomever files the claim first? Common example would be a patient on pulmonary arterial hypertension (PAH) drug that needed an additional, covered, infused drug that is provided by a second supplier.
   
   Response: CR10836 states: "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."
   
   CR10836 also states: "Contractors shall reject an incoming claim line for a G code when a claim in history has paid for a G code visit on the same line item date of service."
   
   As a result of these instructions, the following claim processing rules apply:
   • If two claims with G-codes that belong to the highest payment category are submitted by a single supplier, for the same beneficiary, for the same DOS, the first claim received and processed by the claim processing system will be reimbursed, and the second processed claim will be denied.
   • If two claims with G-codes that belong to different payment categories are submitted by a single supplier, for the same beneficiary, for the same DOS, the claim with a G-code belonging to the highest payment category will be reimbursed, and the claim with a G-code belonging to a lower payment category will be denied.
   • If two claims with G-codes that belong to the highest payment category are billed by different providers, for the same beneficiary, on the same DOS, the first claim received and processed by the claim processing system will be reimbursed, and the second processed claim will be denied.
   • If two claims with G-codes that belong to different payment categories are submitted by different providers, for the same beneficiary, on the same DOS, the claim with a G-code belonging to the highest payment category will be reimbursed, and the claim with a G-code belonging to a lower payment category will be denied.
      
6. I understand that the Home Infusion Therapy Service G-code must be filed within 30 days of a payable J-coded infusion drug. Does within 30 days refer to the time between the date of service of the drug and the date of service of the professional services?
   
   Response: CR10836 states: "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." [Emphasis Added]
   
   Thus, 30-days refers to the time between the DOS on the claim for the J-coded infusion drug and DOS on the claim for the Home Infusion Therapy Services G-code.
    
7. Does the 365-day filing limit apply to Service codes?
   
   Response: Sections 1814(a)(1), 1835(a)(1), and 1842(b)(3)(B) of the Social Security Act, as well as 42 C.F.R. §424.44, specify the timely filing limits for all Medicare Fee-For-Service (Part A and Part B) claims. Section 6404 of the Patient Protection and Affordable Care Act (the Affordable Care Act) reduced the maximum period for submission of all Medicare Fee-For-Service claims to no more than 12 months, or 1 calendar year, after the DOS. These timely filing limits apply to all Medicare claims, including the new home infusion therapy services G-codes.
    
8. What documentation is required to bill for the Home Infusion professional services?
   
   Response: Medicare Program Integrity Manual Chapter 5 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §5.7 notes: "For any DMEPOS item to be covered by Medicare, the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable) ... There must be information in the patient's medical record that supports the medical necessity for the item." [Emphasis Added]
   
   Section 486.520(b) requires that the qualified home infusion therapy supplier ensure that all patients must have a Plan of Care established by a physician that prescribes the type, amount, and duration of home infusion therapy services that are furnished. The Plan of Care must also include the specific medication, the prescribed dosage and frequency as well as the professional services to be utilized for treatment. In addition, the Plan of Care must specify the care and services necessary to meet the patient-specific needs.
   
   As noted in the Final Rule, the skilled services provided on the infusion 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.
    
9. Does the G-code need to be added to the EIP DIF?
   
   Response: No
    
10. Will a DWO that specifies professional services be sufficient to reflect the Plan of Care? Can you provide an example of what would be acceptable?
    
    Response: Medicare Program Integrity Manual Chapter 3 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), Section 3.3.2.1 notes: "For Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met." [Emphasis Added]
    
    Please see response to Question number 8 above for more specific details on the home infusion benefit. A DWO for the home infusion drug (J-code) may note that there are associated home infusion therapy services; however, this notation is not sufficient by itself to support payment. There must be a documented Plan of Care with specific information included as described in the response to Question 8.
     
11. We subcontract our nurse visits to various agencies. Is it permissible to bill subcontracted nursing services under our supplier Tax ID/NPI/PTAN?
    
    Response: The DME MACs suggest that you contact the National Supplier Clearinghouse for a response to this question.
     
12. Are there diagnosis requirements (is coverage limited to Part B-covered services only or is coverage of Part D) nursing also available?
    
    Response: There may be specific diagnoses and other reasonable and necessary coverage requirements associated with the infused drug. See the DME MAC External Infusion Pump Local Coverage Determination (LCD) and LCD-related Policy Articles for additional coverage, coding and documentation requirements. With respect to coverage of Part D nursing services, we suggest that you contact the Medicare Advantage plans with which you are contracted.
     
13. Where may we find the G-code fee schedules?
    
    Response: Consult your DME MAC or the CMS web site for Fee Schedule information.
     
14. Will information regarding the billing of G-codes be included in the DME MAC LCD?
    
    Response: Yes, the information regarding the billing of home infusion therapy services G-codes will be incorporated into an upcoming revision to the DME MAC External Infusion Pump Local Coverage Determination (LCD) and LCD-related Policy Articles.

Additional clarifying information is available in MLN® Number MM10836 and HOME INFUSION THERAPY SERVICES TEMPORARY TRANSITIONAL PAYMENT: FREQUENTLY ASKED QUESTIONS (FAQs) on the CMS web site.

Publication History