A Medicare patient goes home on IV antibiotics, and the pharmacy delivers the drug, the pump, the supplies, and a nurse for the first dose. Medicare Part B pays for almost none of it, because most antibiotics aren’t on the external infusion pump list. The drug falls to the patient’s Part D plan, and the supplies and nursing often aren’t covered by anyone. Situations like that are why home infusion billing starts with benefits verification, not coding.
Key Takeaways
- Commercial plans typically pay home infusion as a per diem (S9xxx codes) for pharmacy services and supplies, plus nursing visits (99601 and 99602) and the drug.
- Medicare Part B covers home infusion drugs only when they’re on the external infusion pump policy’s list, billed to the DME MAC with the pump and supplies.
- Medicare’s home infusion therapy services benefit (G0068 to G0070) pays qualified suppliers for professional services on infusion days.
- Most home IV antibiotics for Medicare patients fall under Part D, which covers the drug but not the supplies, pump, or nursing.
- Infusion pharmacies need state pharmacy licenses, accreditation, and Medicare enrollment as a DMEPOS supplier and, for the services benefit, as a home infusion therapy supplier.
Commercial Per Diem Billing
Most commercial plans and many Medicaid programs pay home infusion using per diem codes. A per diem covers the pharmacy’s professional services, care coordination, supplies, and equipment for each day the patient is on therapy. The per diem code is chosen by therapy type, such as S9500 to S9504 for antibiotics by dosing frequency, S9365 to S9368 for parenteral nutrition by volume, and S9338 for immunotherapy. The drug bills separately by its HCPCS code or NDC and units.
Nursing visits bill separately as 99601 for the first two hours of a home infusion visit and 99602 for each additional hour. Some plans use S9123 or other nursing codes instead, so the contract decides which code set applies. Per diem days should match the days the patient was actually on therapy. Billing through a hold, a hospital stay, or a discontinued order is a common audit finding.
Medicare Part B Infusion Pumps and Drugs
Medicare doesn’t have a general home infusion drug benefit. Instead, Part B covers certain drugs when they’re given through a durable external infusion pump, under the DME MAC’s policy for external infusion pumps. The covered list includes drugs such as inotropes for heart failure, certain chemotherapy agents, some pain medications for intractable cancer pain, and subcutaneous immune globulin. The pump (such as E0779 to E0781), the supplies, and the drug are billed to the DME MAC by the enrolled supplier.
Drugs that aren’t on that list, including most IV antibiotics, aren’t covered under Part B at home. Those usually fall under the patient’s Part D plan, which pays for the drug itself but not the supplies, pump, or nursing. Patients need to know about that gap before therapy starts, and an Advance Beneficiary Notice applies when a Part B item may not be covered.
Medicare also pays for immune globulin given at home to patients with primary immune deficiency under its own benefit, with the drug and the related items and services billed together.
Medicare Home Infusion Therapy Services
Since 2021, Medicare has paid qualified home infusion therapy suppliers for professional services, such as nursing, patient training, and monitoring, on days when the patient receives an infusion drug covered under the pump policy and a professional is in the home. These services bill per visit day under three categories. G0068 covers category 1 drugs such as inotropes and antibiotics given by pump, G0069 covers subcutaneous immunotherapy, and G0070 covers certain chemotherapy. The first visit in a home uses G0088 to G0090 instead.
These claims go to the A/B MAC, not the DME MAC. A patient who’s under a home health plan of care can’t receive home infusion therapy services at the same time, so the two benefits have to be checked against each other. The CMS home infusion therapy page lists current categories and payment rates.
Prior Authorization and Documentation
Most commercial plans require prior authorization for home infusion, and specialty drugs often need their own approval. Authorizations usually set the drug, dose, frequency, and a date range. If any of those change, such as a dose increase or an extended course, the authorization has to be updated before the next claim. When the approval doesn’t match what’s billed, the claim can deny even though therapy was approved, which we cover in why an approved authorization can still end in a denied claim.
Every claim depends on a current, signed prescriber order, the diagnosis supporting the therapy, delivery records, and nursing notes for each visit. For drugs covered under Medicare’s pump policy, the record also has to show the patient meets that policy’s coverage criteria. Practices that refer chemotherapy patients for home infusion follow the rules on our oncology page.
Home Infusion Credentialing
Licensure and accreditation
Infusion pharmacies need a pharmacy license in their own state and nonresident pharmacy licenses in each state where they ship. Many payers and Medicare require accreditation from an organization such as ACHC or The Joint Commission. Nursing agencies that provide infusion visits may need their own state licenses.
Medicare enrollment
To bill pumps, supplies, and covered drugs, the pharmacy enrolls with Medicare as a DMEPOS supplier through the CMS-855S, which requires accreditation and a surety bond. To bill the home infusion therapy services benefit, the pharmacy enrolls separately as a home infusion therapy supplier with the A/B MAC. Each enrollment has its own revalidation cycle.
Commercial networks
Many commercial plans limit home infusion to contracted networks, and some route specialty drugs to their own specialty pharmacies. Until the pharmacy is contracted, its claims go out of network or deny. Our credentialing team handles pharmacy licenses, accreditation documents, Medicare enrollments, and payer contracts together, since you can’t bill what you can’t credential.
Home Infusion Billing FAQs
How do commercial plans pay for home infusion?
Most use a per diem code (S9xxx) for pharmacy services, supplies, and equipment for each day on therapy, plus nursing visits billed as 99601 and 99602 and the drug billed by its HCPCS code or NDC.
Does Medicare cover home IV antibiotics?
Not under Part B in most cases. IV antibiotics usually fall under the patient’s Part D plan, which covers the drug but not the supplies, pump, or nursing.
Which home infusion drugs does Medicare Part B cover?
Drugs on the DME MAC’s external infusion pump policy, such as inotropes, certain chemotherapy agents, some pain medications for intractable cancer pain, and subcutaneous immune globulin. Immune globulin for primary immune deficiency has its own home benefit.
What are G0068, G0069, and G0070?
They’re Medicare’s home infusion therapy services codes, billed per visit day by enrolled suppliers for professional services. G0068 covers category 1 drugs, G0069 subcutaneous immunotherapy, and G0070 certain chemotherapy.
How are home infusion nursing visits billed?
Commercially, as 99601 for the first two hours and 99602 for each additional hour, unless the contract specifies another code. Under Medicare, professional services on infusion days bill through the home infusion therapy services codes.
What enrollment does a home infusion pharmacy need with Medicare?
DMEPOS supplier enrollment through the CMS-855S to bill pumps, supplies, and covered drugs, and separate enrollment as a home infusion therapy supplier to bill the services benefit.
Home Infusion Billing Handled by Medwave
Home infusion gets billed in pieces, with the drug, the per diem, the nursing visits, and the professional services often going to different payers or benefits. Medwave routes Medicare home infusion therapy services, Part B drugs, and Part D drugs to the right place and tracks authorizations for each. Our billing team keeps home infusion at a 98% clean claim rate.
Pharmacies need DME supplier enrollment, home infusion therapy supplier enrollment, and pharmacy network contracts. Our credentialing team handles those in about 85 days on average, and our payer contracting work covers per diem rates with commercial plans.
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