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. The use of “local” or proprietary (i.e., 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. 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. 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 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. 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. A Quick Reference is Worth a Thousand Words! Thanks to the generous support from WellSky the 2018 Quick Coding Reference for Home Infusion Therapy is available as a member benefit. The Quick Coding Reference is an extremely useful tool once the concepts and detail in the National Coding Standard are understood. Importantly, NHIA’s Quick Coding Reference visually demonstrates that using the home infusion therapy per diem coding system is actually quite simple—it is administratively efficient and easy to incorporate into managed care contracting and government payer fee schedules. See page 149 for details. As additional assistance to you, NHIA’s Home Infusion EDI Coalition (HIEC) can provide assistance on questions on home infusion therapy service coding or the transition to per diem coding not addressed in the National Coding Standard. Questions should be submitted via e-mail to email@example.com; subject line: Coding Inquiry. We will provide rapid responses (within one week) when possible. Some questions may be sent to the full HIEC Committee for consideration during its regularly scheduled meetings, and we may invite you to participate. We will post questions and responses of wide interest on NHIA’s Home Infusion Coding FAQ page in the HIEC section of the association’s web site, www.nhia.org . For information about the National Home Infusion Association, visit our web site at www.nhia.org or call 703-549-3740.
1 Healthcare Common Procedure Coding System. 2 National Drug Code. Administered by U.S. Food and Drug Administration.