infusion therapy
What the 21st Century Cures Act means for HIT reimbursements
by Jen Keiser

A necessary presence in home infusion treatments, nurses provide training and support for infusion equipment, both on location and remotely, as well as caring for and maintaining the vascular site for patients. When these nursing services weren’t covered by Medicare, HIT providers had to account for these expenses as part
of the overhead of being in the home infusion business.    

In 2016, nurses in the home infusion therapy (HIT) industry achieved an important milestone when Congress signed the 21st Century Cures Act into law. As part of this wide-reaching law, Medicare Part B coverage was amended to include professional services, including nursing, for HIT reimbursement—and scheduled to take effect in January 2021.

The Bipartisan Budget Act of 2018 also funded a transitional period from January 2019 to December 2020, which allowed qualified HIT pharmacies to bill for nursing services. Now, heading into 2021, home health agencies (HHAs) can also apply to become qualified HIT suppliers in order to directly bill professional services to Medicare.

Although this new process may be daunting, the change presents an opportunity to increase revenue. With a proper understanding of how to utilize it effectively, HHAs can use the Cures Act-triggered changes as an important new revenue source and a way to get reimbursement for the essential services home infusion nurses are already providing. To ease the transition, here’s what you need to know to take advantage of this portion of the Cures Act.

Certification Highlights

Home health agencies that participated indirectly during the transitional period will need to note several changes going into the permanent period. For the last two years, patients with a homebound status continued to fall under episodic payments. But if the homebound status was not in play, nursing services from HHAs were subcontracted and billed through home infusion pharmacies. From there, they would be billed to one of four Durable Medical Equipment Medical Administrative Contractors (DME MACs), as HIT pharmacies were the only type of qualified Medicare Part B home infusion therapy supplier under the Budget Act.

Starting in January 2021, home health agencies can choose to become certified as a Medicare Part B home infusion therapy services supplier (specialty code D6) in order to directly bill Medicare for nursing services provided with qualified HIT drugs. The Centers for Medicare & Medicaid Services (CMS) website includes complete information on the enrollment applications and process.

Agencies interested in going in this direction will require certification from one of the six CMS-approved accrediting organizations:

  • Accreditation Commission for Health Care, Inc. (ACHC)
  • Community Health Accreditation Partner (CHAP)
  • National Association of Boards of Pharmacy (NABP)
  • The Compliance Team (TCT)
  • The Joint Commission (TJC)
  • Utilization Review Accreditation Commission (URAC)

What Qualifies for Reimbursement?

There are also specific guidelines for which types of HIT visits qualify for reimbursement; only therapies that are covered under the external infusion pump (HCPCS code L33794) local coverage determination listed under each region’s DME MAC’s website can be billed.

While some nurses do provide support remotely, only visits in which nurses are physically on-site on the day that an applicable drug is administered—and within 30 days of the drug being dispensed—can be billed for reimbursement. Additionally, patients being provided services by an HHA under a 60-day home health care episode cannot have separate HIT nursing services billed to Medicare within that time period. This differs from the policy set out in the transitional period under the Budget Act.

It’s also worth noting that the medications themselves will still be filed for reimbursement by the home infusion pharmacy, not the HHA.

Table 1

Table 1: G-Codes

How to Bill

During the transitional period, HIT pharmacies filed claims for HIT nursing services through one of four DME MACs. Moving into 2021, all qualified HIT suppliers, including HHAs and pharmacies, will need to file claims to one of 12 Medicare Part A/Part B MACs instead. Professional services for qualifying HIT visits are billed using one of the six G-codes, which determine the amount of reimbursement, laid out in Table 1.

The category is determined by the medication the patient is receiving. Here is how it works:

  1. To bill for nursing services, you will use G-codes (Table 1), with the category defined by the type of drug used (Table 2.1-2.3) and further modified by whether a service is an initial or subsequent visit. Helpful hint: Only one G-code is allowed per day, so if multiple prescriptions are being administered during a single day, pick the G-code with the highest reimbursement (i.e., the highest category level).
  2. Along with the G-code, you will also need to provide a number of units to represent the length of the HIT visit. This number is determined by the amount of time a nurse has spent on site with the patient, as outlined in Table 3. 
  3. As you are submitting your own claims, you should work with your HIT pharmacy partner to ensure that they have submitted a claim with a qualifying J-code for the infusion drug itself, so it is incorporated into the common working file (CWF). J-codes must be submitted within the same 30-day time period as the corresponding G-code in order to be processed correctly. If a J-code is not found in the patient’s CWF record when your G-code is submitted, your claim will be recycled and brought up again after five days, a process done up to three times. If no match is found after three cycles, your claim will be denied.

Table 2

Table 2-1: J-Codes, Category 1

Table 2 B

Table 2-2: J-Codes, Category 2

Table 2 C

Table 2-3: J-Codes, Category 3

Best Practices

For HHAs that want to take advantage of this opportunity to increase their revenue but are wary of regulatory changes, there are some key ways to make sure you are taking full advantage of the new framework:

  • Research the guidelines published by CMS and industry trade associations, including:
    • MLN Matters MM11880 Billing for Home Infusion Therapy Services on or After January 1, 2021
    • Complete Guide to Medicare Part B for Home Infusion Therapy Services
  • Keep your employees informed about the latest regulatory and operational changes by providing them with educational webinars and the many online resources available from technology providers and media outlets. Use internal communications programs within your agency to make sure all staff are aligned to succeed.
  • Look for a software provider that is regularly enhancing its technology to reflect the latest regulatory updates and offers features such as the ability to submit claims in 837P and CMS-1500 formats, which HHAs may not run into frequently.
  • Establish points of coordination between your agency and the home infusion pharmacy or pharmacies you work with to ensure a smooth billing process, especially in this new structure that requires pharmacy and nursing reimbursement requests to be aligned.

By using the instructions and best practices outlined here, your home health agency can approach this new framework with confidence that you are taking advantage of all the Cures Act has to offer and maximizing your reimbursement—with minimal headaches.

Table 3

Table 3: Visit Length Units

Jen Keiser is a senior director of pharmacy product management at Brightree. She has almost three decades of experience in the home health industry developing and supporting software applications for home infusion, specialty pharmacy, HME and home health providers. She has also held previous technology leadership positions at CVS Health and Mediware Information Systems.