NHIA National Coding Standard for Home Infusion …

1 NHIA National Coding Standard for home Infusion Claims under HIPAA Version Effective Date: January 1, 2013 100 Daingerfield Road Alexandria, VA 22314 Phone: 703-549-3740 Fax: 703-683-1484 COPYRIGHT 2013, NHIA - ALL RIGHTS RESERVED Page 2 of 140 Table of Contents I. Introduction and Page 6 II. General Page 8 home Infusion Codes Added to HIPAA-Approved HCPCS Codes Per Diem: The Conceptual Framework for the Coding System Coding for Drugs: NDC Numbers or HCPCS Codes? S Codes for home Infusion Are Permanent The home Infusion Provider and home Infusion Therapy The Electronic claim Format New Code Requests Meaning of Standard Revisions to the National Coding Standard NHIA Copyright What s New?

2 III. Procedures for Use of the HIPAA-Approved Billing Page 17 Most Therapies Anti-infective Therapies Chemotherapy Enteral Nutrition Hydration Therapy Pain Management Total Parenteral Nutrition (TPN) COPYRIGHT 2013, NHIA - ALL RIGHTS RESERVED Page 3 of 140 III. Procedures for Use of the HIPAA-Approved Billing Codes (continued) Specialty Therapies Not Otherwise Classified (NOC) Therapies Catheter Care home Nursing Services for Infusion /Specialty Drug Administration Nursing -SD Modifier Catheter Care Insertion Nursing Services in Ambulatory Infusion Suite of the home Infusion Therapy Provider (AIS) Unusual or High Risk/Escort Travel Other Specialized home Services Unusual or High Risk/Escort Travel Extra Services (Reserved for future use)

3 Professional Pharmacy Services Professional Pharmacy Services Code After Hours, Emergency and Out of Office Services Unusual or High Risk/Escort Travel Pediatric Services Ambulatory Infusion Suite of the home Infusion Therapy Provider (AIS) All Services for Therapy Provided in the AIS Occasional Occurrence of Treatment in the AIS After Hours, Emergency and Out of Office Services Coding for Place of Service Modifiers COPYRIGHT 2013, NHIA - ALL RIGHTS RESERVED Page 4 of 140 IV. claim Coding Page 41 Coding for Billing of Drugs Coding Drugs with NDC Numbers is Superior for home Infusion Claims Primer on NDC Numbers Using NDC Coding for Reimbursement Coding of Drugs in the X12N 837 Electronic claim Claiming of Nursing Encounters May or May Not Be on Same claim Claims Are for Submission of Charges Importance of Electronic claim Submission Use of Trade Names and NDC Numbers Examples Build Upon Each Other Comprehensive Examples: home Infusion Therapy and Ambulatory Infusion Suite of the home Infusion Therapy Provider (AIS) Page 49 Addendum Example.

4 HIPAA-Compliant X12N 837 Professional home Infusion Therapy Page 86 V. National Definition of Per Page 92 VI. HIPAA-Approved Code System for Per Diem Coding of home Infusion Page 98 COPYRIGHT 2013, NHIA - ALL RIGHTS RESERVED Page 5 of 140 VII. HIPAA Regulations on Requiring Standard Coding and Electronic claim Transactions Page 128 Can HCPCS or CPT code descriptions be changed by payers or providers? Must providers and payers break out Coding for all of the dispensed drugs? Must providers and payers break out Coding for home Infusion nursing visits? Through which electronic format are home Infusion therapy claims submitted?

5 CPT is a registered trademark of the American Medical Association. NHIA's Quick Coding Page 135 The NHIA Model Contract Page 136 NHIA s Medicare Billing for Denial Reference Tool .. Page 140 COPYRIGHT 2013, NHIA - ALL RIGHTS RESERVED Page 6 of 140 I. Introduction and Overview The Health Insurance Portability and Accountability Act (HIPAA) requires that health care payers use only Standard medical code sets and make Standard electronic transactions available for health insurance transactions. Under HIPAA regulations, payers are required to accept only approved medical code sets.

6 The use of local or proprietary ( , payer-specific) medical Coding is not allowed. The HCPCS1 codes from the Centers for Medicare & Medicaid Services (CMS) include a comprehensive set of per diem codes that are widely used by most commercial and some government payers to process home Infusion claims. This National Coding Standard from the National home Infusion Association (NHIA) presents these codes as a comprehensive Coding system for home Infusion claims and provides procedures for and training on their use. HCPCS contains the only HIPAA-approved, comprehensive code set available to submit home Infusion and ambulatory Infusion suite claims that supports the typical per diem contracts present in the marketplace.

7 For both providers and payers, the National Coding Standard presents HCPCS as a system used for assigning codes within their provider-payer contracts for submission of claims. NHIA understands that providers and payers have found their per diem based contracts match this system of HCPCS codes well. Payers that may still be funding home Infusion therapy services through detailed billing code methodologies often subject to high administrative expense and error---will find this document useful for understanding the superior per diem methodology and planning conversion to it.

8 For example, state Medicaid health plans may use the codes presented in this National Coding Standard . The National Coding Standard does not address submission of claims to Medicare Parts A, B or D. For providers, a purpose of this document is to serve as a tutorial for Coding of claims. For payers, this document serves as a tutorial for claims processors and claim -processing system designers on what they can expect in a claim submitted by a home Infusion provider. The HCPCS codes presented in the National Coding Standard are a claims procedure Coding system for medical services that include home Infusion therapies, home enteral therapies, specialty drug therapies, disease state and care management services, and services 1 Healthcare Common Procedure Coding System.

9 COPYRIGHT 2013, NHIA - ALL RIGHTS RESERVED Page 7 of 140 provided in the Ambulatory Infusion Suite of the home Infusion therapy provider (AIS). Combined with use of NDC2 numbers and HCPCS for the Coding of drug products, and CPT and HCPCS codes for home nurse visits, these medical services are coded under the per diem approach using the HIPAA-approved codes listed in Section VI HIPAA-Approved Coding System for Per Diem Coding of home Infusion Therapy. Use of the per diem HCPCS codes is now the universal, National Standard for submission of per diem claims for home Infusion therapy. The National Coding Standard is provided free of charge as a service from the National home Infusion Association to assist your organization in complying with the HIPAA standardized Coding requirements.

10 For those still transitioning, the goal is to make your transition to this HIPAA-compliant Coding structure as easy as possible. For all who have completed transition, the goal is to provide a valuable and current home Infusion therapy Coding and claiming reference resource to guide you for implementing Coding changes and other new developments that occur. For example, in the National Coding Standard release effective for use on January 1, 2005 we published the first National Coding Standard available for services provided in the Ambulatory Infusion Suite of the home Infusion therapy provider (AIS) using standardized and specific HCPCS codes.