Geisinger Gold aligns with Medicare regulations for home infusion therapy billing

Effective January 1, 2026, Geisinger Health Plan (GHP) will implement changes to align with existing Medicare standards for home infusion therapy and nursing services under Geisinger Gold (Medicare Advantage) plans.

What’s changing?

• S and 99 codes billed for the administration of home infusion drugs are no longer payable for dates of service on or after January 1, 2026.
• Claims submitted with these codes will deny non-Medicare covered, provider liability.

Providers should follow Medicare guidelines in the additional resources below to avoid claim denials.

Reason for alignment

Effective January 1, 2021, congress introduced a separate Medicare payment for professional services related to home infusion therapy. GHP is aligning with Medicare’s home infusion therapy services benefit established under Section 5012 of the 21st Century Cures Act and codified in Sections 1861(s)(2)(GG) and 1861(iii) of the Social Security Act. This benefit is not inclusive of Medicare Part B drugs.

Medicare home infusion therapy services benefit

• Covers professional services furnished by a qualified home infusion therapy supplier, accredited by a Medicare-approved organization, in the patient’s home, including:
• Nursing services
• Patient training and education (not otherwise covered under the DME benefit)
• Remote monitoring and monitoring services
• Services must be furnished in accordance with a physician-established plan of care.
• Applies only to drugs and biologicals requiring infusion through an external infusion pump that qualifies as durable medical equipment (DME) and is necessary for the treatment of an illness/injury.
  

Durable Medical Equipment (DME) benefit

• The external infusion pump and related supplies (including home infusion drugs) remain covered under the DME benefit.
• Drugs must be billed with the external infusion pump and supplies to be payable under Medicare Part B.
• If the drug is not billed with the pump and supplies or is not incident to a physician’s service, the claim will not be paid.
• Administrative tasks (e.g., preparing supplies, coordinating delivery, pharmacy fees) are not separately reimbursed.

Local Coverage Determination (LCD)

• The professional services related to the home administration of home infusion therapy benefit are only payable for drugs and biologicals billed under the External Infusion Pump LCD (L33794).
• If a drug is not listed in the LCD, it will not be paid.
• A qualified home infusion therapy provider must ensure safe and effective provision and administration of home infusion therapy services on a 7 day a week, 24 hour a day basis. Home infusion therapy services include:
• Professional services including nursing services
• Patient training and education (not covered under the DME benefit)
• Remote monitoring and monitoring services
• Professional services provided in the home must be furnished by a qualified home infusion therapy supplier.

Why S codes are not payable

• S codes are non-billable for Medicare-covered services and do not represent the correct items/services under this benefit.
• Billing with S or 99 codes does not meet Medicare requirements, unless a plan offers supplemental benefits for these services.  Geisinger Gold currently does not offer any supplemental benefits around home infusion therapy.

Additional resources

• External Infusion Pumps LCD (L33794)
• Medicare Benefit Policy Manual – Chapter 15
• Drugs and Biologicals (Section 50)
• Home Infusion Therapy Services (Section 320)
• Home Infusion Therapy Services Benefit FAQ 
  

Action required

Review your billing practices and ensure compliance with Medicare standards for home infusion therapy services. Claims using S and 99 codes for dates of service on or after January 1, 2026, will deny as provider liability.