How Infusion Billing Company Manages Medicare Home Infusion Therapy

Medicare Home Infusion Therapy (HIT) covers professional services linked to infusion medications. It allows patients to receive treatment at home through a durable medical equipment (DME) pump. This benefit was introduced under Section 5012 of the 21st Century Cures Act. HIT covers nursing care, patient training, and home monitoring. It falls under Medicare Part B.

To qualify, healthcare providers must enroll with the specialty code D6. Accreditation from a CMS-approved agency is also required. Billing uses HCPCS G-codes. Earlier codes (G0068–G0070) have been replaced by G0088–G0090. Each code is billed per 15-minute increment, with a limit of one unit per category each day.

CMS releases updated rates each year. Rates are adjusted based on the provider’s location through Geographic Adjustment Factors (GAFs). Patients are responsible for a 20% coinsurance and the Part B deductible. That’s why there’s a need for infusion billing company comes into the picture.

Geographic Adjustment Factors (GAFs)

GAFs are used by Medicare to adjust provider payments for local cost differences. Managing these calculations and paperwork is time-consuming. Healthcare staff often find it hard to handle this while also focusing on patient care. This is where infusion billing services step in. These services manage the administrative side of HIT billing. They ensure correct payment amounts and accurate claim submissions.

Understanding HIT HCPCS Codes

Medicare uses six HCPCS codes for HIT billing. The codes G0088, G0089, and G0090 are for initial home visits. The codes G0068, G0069, and G0070 are for subsequent visits. Each code represents a 15-minute service block. The codes are split into three drug categories:

•    Category 1: G0088/G0068 – IV anti-infectives, pulmonary hypertension drugs.
•    Category 2: G0089/G0069 – Subcutaneous infusions.
•    Category 3: G0090/G0070 – Chemotherapy and complex therapies.

The infusion billing company submits these G-codes on the CMS-1500 form to Part B MACs. CMS compliance rules must be followed for all claims.

Documentation Requirements

Hospitals work with physicians to create and maintain the HIT care plan. Documentation must prove patient eligibility and medical need. It must also list the drug given, with its J-code, route, and infusion duration. Records should include details of vascular access care.

Notes on patient education and home monitoring must be kept. Physician notifications about available care settings should also be documented. Providers must keep proof of accreditation. Medicare enrollment under specialty code D6 is also required.

Medicare HIT Policies

The HIT benefit was created by amending sections of the Social Security Act. It covers nursing services, patient education, and monitoring through a DME pump. The pump, drugs, and supplies are still billed under the DME benefit.

Providers must meet health and safety standards in 42 CFR 486 Subpart I. PECOS enrollment as a Part B provider under code D6 is required. Accreditation must come from a CMS-recognized body like The Joint Commission, ACHC, or URAC.

Billing Regulations

HIT service claims are submitted on the CMS-1500 form (or 837P electronic). G-codes are entered in Box 24D with the right modifiers. Medicare pays for only one unit per drug category per day. If multiple providers bill the same day, only the highest-paying code is reimbursed.

Medicare’s Common Working File checks for a matching drug J-code. If no match appears within 30 days, the claim is rejected. Claims must be filed within 12 months of the service. Part B coinsurance and deductibles apply to all HIT payments.

Updated HIT Codes

CMS currently defines six G-codes for HIT services:

•    Category 1: G0088/G0068 – IV anti-infectives, pain management, inotropes.
•    Category 2: G0089/G0069 – Subcutaneous infusions.
•    Category 3: G0090/G0070 – Chemotherapy and other high-complexity drugs.

These codes cover professional services in 15-minute blocks. Only one unit per category per day is paid. Key CMS Change Requests like CR11880, CR12062, CR12108, and CR12324 update policy details. Providers must review Medicare publications for the latest guidance.

The Role of an Infusion Billing Company

Infusion billing services make HIT billing easier. Their teams know the exact G-codes and modifiers to use. Claims are checked for accuracy before submission. Experts apply modifiers JW or JZ where needed. J-codes are matched correctly to the drug. Compliance with National Home Infusion Association (NHIA) standards is ensured.

Help with Prior Authorization

Prior authorization is often a slow and complex process. Each payer has its own rules. Infusion billing experts verify insurance coverage, gather documents, and submit requests quickly. This prevents claim denials. The outsourced infusion billing company also frees healthcare staff to focus on patient care instead of paperwork.

Cost Savings

In-house billing teams require high investment. Costs include salaries, training, and office space. Keeping staff updated on coding changes also takes time and resources. Outsourcing to infusion billing companies cuts costs by up to 80%. Experts are already trained and work in company-provided spaces. This means lower overhead for the healthcare provider.

Why Accuracy Matters in HIT Billing

Mistakes in HIT billing can delay payment or cause denials. Accurate coding ensures faster reimbursement. It also keeps providers compliant with CMS rules. Infusion billing services audit each claim. They ensure codes match services and documentation. This reduces revenue loss and keeps cash flow steady.

Medicare Part B enrollment and CMS accreditation are essential for HIT providers. Infusion billing services help meet these requirements. They also keep providers compliant with G-code rules and locality-adjusted rates. Using NHIA’s coding standards and compliance software, billing experts update codes and rates automatically.

The outsourced infusion billing company performs documentation audits, file claims on time, and train staff. This reduces denials and improves reimbursement rates. Partnering with these services lowers stress for healthcare teams. It also ensures patients get their home infusion care without delays. Efficient HIT billing supports both financial stability and patient care quality.