Page 303 - Medicare Benefit Policy Manual

exclusion list. These drugs continue to be paid for under the DME benefit as supply
drugs to the covered infusion pump. Any additional training and education services
needed for the patient to administer these drugs at home would be covered under this
home infusion therapy services benefit.

There are other infusion drugs covered under Part B that could potentially be added to the
DME LCD for External Infusion Pumps (L33794) and thus qualify for services under the
home infusion therapy services benefit. Allowing the DME MACs to maintain the list of
infusion drugs and biologicals ensures quarterly review of any and all medications that
meet the criteria for external infusion pumps, thus ensuring an up to date, inclusive
benefit.

320.8 - Payment for Home Infusion Therapy Services
(Rev. 10547, Issued: 12-31-20, Effective: 01-01-21, Implementation: 01-04-21)

A unit of single payment is made for items and services furnished by a qualified home
infusion therapy supplier per payment category for each infusion drug administration
calendar day. The single payment amount represents payment in full for all costs
associated with the furnishing of home infusion therapy services.

320.8.1 - Home Infusion Drug Payment Categories
(Rev. 10547, Issued: 12-31-20, Effective: 01-01-21, Implementation: 01-04-21)

Payment for home infusion therapy services is contingent upon a corresponding home
infusion drug being covered and paid for under the DME benefit. Therefore, home
infusion therapy suppliers must ensure that the appropriate drug is billed by the DME
supplier no more than 30 days prior to the home infusion therapy service visit.

Home infusion drugs are assigned to three payment categories, as determined by the
HCPCS J-code:

- Payment category 1 includes certain intravenous infusion drugs for therapy,
prophylaxis, or diagnosis, such as antifungals and antivirals, inotropic and
pulmonary hypertension drugs, pain management drugs, chelation drugs; but
excludes chemotherapy and other highly complex drugs or biologicals.

- Payment category 2 includes subcutaneous infusions for therapy or prophylaxis,
such as certain subcutaneous immunotherapy infusions.

- Payment category 3 includes intravenous chemotherapy infusions, including
certain chemotherapy drugs, and other highly complex drugs and biologicals.

Specific billing codes are associated with each of the three payment categories in order
for qualified home infusion therapy suppliers to bill Medicare for home infusion therapy
services on an infusion drug administration calendar day.