Home Infusion Therapy BlueChoice Schedules Effective 11/1/15

Reimbursement Changes/Updates 

The Drug/Injectable Fee Schedule will be updated on March 1, June 1, September 1 and December 1 each year.

Codes not listed may require individual consideration to determine the BCBSTX compensation allowable amount.

CPT/HCPCS Drug Schedule

The NDC Fee Schedule will be updated monthly.

The allowed amount posted for each NDC reflects one unit of measure.  Certain drugs may be administered as partial units (i.e., 0.5 or 0.7), while others may be multiple units (i.e., 2 or 5).  The correct NDC units provided (whether partial, single or multiple) should be used as the multiplier to determine the actual allowed amount.

NDC Drug Schedules

Codes not listed may require individual consideration (IC) to determine the BCBSTX compensation allowable amount.

Other Codes Schedule

All-inclusive Per Diem Rates are limited to the following charges:

a. IV solutions, if applicable to the therapy provided;
b. Professional pharmacy services;
c. Administrative services;
d. Care coordination; and
e. All necessary supplies and equipment, including delivery.

The Per Diem Rate is applicable only to the day(s) on which an actual infusion service and/or nursing care is provided.

The Ancillary Provider must obtain Pre-authorization/Pre-certification for all services. Around-the-clock private duty nursing and home health aide services are not eligible for payment.

Concurrent Therapies: All concurrent therapies must be billed with the SH and SJ Modifiers when appropriate.

SH Modifier = Second concurrently administered infusion therapy and will be reimbursed 50% of the maximum allowable.

SJ Modifier = Third or more concurrently administered infusion therapy and will be reimbursed 0% of the maximum allowable.