National Per Diem Coding Assured for Home Infusion Under HIPAA Effective January 1, 2002

(Updated December 4, 2007; Original Post October 1, 2001)

Successful Outcome to NHIA's Campaign

The National Home Infusion Association was pleased to announce that nationally standardized coding for home infusion therapy services were made available for use by providers and payers in 2002. These codes are compliant with federal HIPAA regulations that mandated that all public and private payers use "approved" standardized coding for all of their health care transactions.

In October of 2001, the Center for Medicare & Medicaid Services (CMS) released its updated set of HCPCS (Healthcare Common Procedure Coding System) codes for 2002. This updated code list included approximately 80 "S-codes" that closely mirrored the NHIA HIEC Coding System formerly maintained by the association.

The S-codes provide a comprehensive coding system that meets the vast majority of coding needs of both providers and payers. Like NHIA's HIEC system, the S-codes provide therapy-specific, per diem codes for virtually all the home infusion and specialty drug therapies provided by NHIA members.

Each per diem code specifically includes "administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment." Drugs and nursing visits are coded separately. In addition, for those cases in which a per diem code is not appropriate or desired by the payer, pharmacies providing infusion therapies, specialty drugs, and disease management services may bill separately for the professional pharmacy services they provide, on an hourly basis.

Background
The development of standardized coding and electronic claiming capability for the home infusion provider and payer community has been one of NHIA's priority issues. This effort intensified with the publication of the federal Health Insurance Portability and Accountability Act (HIPAA) regulations in August 2000, which required that health care payers use standardized code sets, end use of local and custom codes, and make electronic transactions available for all claims transactions.

HIPAA regulations support NHIA's position that infusion therapy claims are major medical ("professional") claims, not retail drug claims. However, they did not specify which codes could be used for home infusion claims, while disallowing use of the many local and custom codes that had been in use to submit home infusion claims.

Under the regulations, the only service billing codes that were "HIPAA-approved" for professional claims were CPT® codes, which are owned and maintained by the American Medical Association, and HCPCS, which are administered by CMS. Prior to 2002, neither code set had met the business needs of the payers and providers of home infusion therapy.

NHIA's Advocacy on This Issue
NHIA worked aggressively on the development of standardized coding, due to the profound benefits that our members would reap from standardized coding and electronic claiming. NHIA also believes that the per diem model is the only effective model that ensures appropriate coverage and reimbursement for the wide range of professional services and supplies that comprise home infusion therapy. As HIPAA moved the health care world towards standardized coding, NHIA felt it was imperative that a per diem coding system be available that would allow providers and payers the level of specificity needed to process claims accurately, appropriately, and efficiently.

In the early-2000s, NHIA's Home Infusion EDI Committee (HIEC) undertook very visible, public steps to gain specific approval for the association's HIEC Coding System as an approved medical code set under HIPAA. However, the association met with mounting obstacles to that approach as policymakers sought to avoid the approval of code sets in addition to the HCPCS and CPT systems. For the benefit of our members, NHIA chose to also direct efforts toward working with decision-makers in the HCPCS and CPT systems to educate them regarding home infusion coding issues, private sector payment methodologies for these services, and the range of products and services included in the home infusion per diem. NHIA also introduced these decision-makers to a truly state-of-the-art coding system-NHIA's HIEC Coding System. The association believes NHIA's role in providing this information and its HIEC Coding System to the HCPCS decision-makers was critical to this success, in that it confirmed data the decision-makers had obtained from other sources and organized the codes needed into a complete code structure.

"The achievement of standardized coding for home infusion represents a huge step forward for our community," said Lorrie Kline Kaplan who was NHIA Executive Director at that time. "It will not only improve our business efficiency and timeliness of claims payment, but will also provide a model for home infusion service coverage. NHIA set the standard for how home infusion claims should be coded, and we are very proud that this model has been adopted into the HCPCS system." The HIEC committee will have an ongoing role in facilitating the transition to the new S-codes and electronic claiming, as well as providing a resource to identify and facilitate new infusion therapy coding needs as they arise, she added.

"NHIA's HIEC initiative has been a phenomenal volunteer effort," added then-NHIA President Ken Speidel, Pharm.D., of Akron, Ohio-based Ritzman Infusion Services. "This victory simply would not have been possible without the tremendous commitment of the HIEC leadership and so many dedicated volunteers." In addition to HIEC Chair Bruce E. Rodman (Abbott Home Infusion Services) and Vice Chair Len Holman, R.Ph. (Option Care of Northeast Ohio), key HIEC volunteers at that time had included Mary Clark (Apria Healthcare), David Franklin, M.S.A. (Bon Secours Cottage Health System), Christopher J. Maksym, Pharm.D. (University of Michigan/HomeMed), Joseph Pomis (Endoxy Healthcare), and Mike Rigas, Pharm.D. (Apria Healthcare). (Their company affiliations listed as of October 2001.)  Dozens of other infusion providers and payers also assisted in the HIEC initiative that started in 1994.

At that time, then-HIEC Committee Chair Bruce E. Rodman noted that the Committee was confident this new HCPCS code set would be widely accepted by payers, becoming the sole, nationally-recognized solution for per diem coding of home infusion services on health claims. That observation has become reality.

The National Home Infusion Association, based in Alexandria, Virginia, is a trade association that represents and advances the interests of organizations and individuals that provide infusion and specialized pharmacy products and services to the entire spectrum of home-based patients. For more information, call Russ Bodoff at 703-549-3740 or visit the association at www.nhia.org.

For more information about HIEC, home infusion coding, and the home infusion per diem, visit the HIEC area of the NHIA website.

CPT® is a registered trademark of the American Medical Association.