Precertification is not required. Documentation supporting the medical necessity should be legible, maintained in the patient's medical record and must be made available to HMSA upon request. HMSA reserves the right to perform retrospective review using the above criteria to validate if services rendered met payment determination criteria.
Claims Filing Information
Please use the codes listed below when submitting claims for pain management therapy.
Pain Management Therapy Codes
| Code | Description |
| S9325 | Home infusion therapy, pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment, (drugs and nursing visits coded separately), per diem (do not use this code with S9326, S9327 or S9328) |
| S9326 | Home infusion therapy, continuous (twenty-four hours or more) pain management infusion; administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem |
| S9327 | Home infusion therapy, intermittent (less than twenty-four hours) pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem |
| S9328 | Home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem |
| 99601, 99602 | Nursing care |
Billing drugs administered
Identify the drug administered using the specific HCPCS code when available. Use the unlisted HCPC code (J3490) and NDC number only when a specific HCPC code is not available. For specialty pharmacies, please refer to Billing for Injectable Drugs (Non-Vaccines).
Nursing services (CPT codes 99601 and 99602) are covered and do not require precertification. Nursing services may be billed separately and are not included in the per diem for IV therapy.
When billing the per diem charge for an additional pain management drug administered on the same day, code a second service line with the appropriate per diem code and modifier code SH. Bill each pain management drug separately, being sure to note the correct NDC number for each agent.
Example
The patient has cancer with metastasis to the bones. The attending physician has prescribed chronic pain management therapy using morphine sulfate at 5 mg/hr, 24 hours a day. The provider bills for on month's service.
The provider bills the per diem charge for pain management therapy on the first service line.
S9325 x 31 units
Drug Unit Calculations
The unit calculations for this drug are complex. We suggest that the billing clerk ask the pharmacist to calculate the units in such a case.
The patient is receiving 5 milligrams per hour. In 24 hours, she will have received 120 milligrams. The drug concentration is 25 mg/mL; therefore, to calculate milliliters divide by 25. The quotient, 4.8 milliliters, is the amount the patient is receiving per day.
In 31 days, the patient will have used 148.8 milliliters (rounded off to 149 milliliters).
J3490 NDC: 00074-1133-03 x 149 units
For more information, please see the Home Infusion Pain Management Therapy medical policy.
