Q&A: Determining HIT reimbursement

Q: How does Medicare reimburse for home infusion therapy (HIT)?

A: CMS is required by statute to set a payment rate for the HIT services that differentiates by type of infusion therapy and accounts for variations in utilization of services by therapy type. In addition, the payment rate is required to be adjusted to reflect geographic wage index and other costs that vary by region, patient acuity, and complexity of drug administration. The payment rates cannot exceed the amount determined under the Medicare Physician Fee Schedule (MPFS) for infusion therapy services if furnished in a physician’s office. To effectuate this “cap,” the statute mandates that the payment rates cannot reflect more than five hours of infusion for a particular therapy per calendar day, and as a result of this statutory requirement, CMS limits payments for HIT to no more than four hours of what payment for similar services would be under the MPFS.

Payment rates are established by type of infusion drug and whether the visit is the first or subsequent visit. Drugs are grouped into three different categories and billing is per 15 minutes using appropriate CPT codes for infusion. Payment category 1 includes antifungals and antivirals, uninterrupted long-term infusions, pain management, inotropic, and chelation drugs. Payment category 2 includes subcutaneous immunotherapy infusions. Payment category 3 includes certain chemotherapy drugs. Only one payment amount is made for each day of in-person HIT service, and HIT services are billed on the 1500 professional claim form. The 2021 Home Health proposed rule includes a list of the various payment rates in Table 15.

For more information, see "Note from the instructor: Does COVID-19 warrant consideration of home infusion therapy?," by Valerie A. Rinkle, MPA, CHRI.