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Small Mistakes in Medicare Infusion Billing that Cost Big

Written by: Brenda Langlais on Tuesday, February 9, 2016 Posted in: Home Infusion

calculatorYou prepare and submit your infusion billing to Medicare and expect payment. Seems pretty simple. So why do so many claims get rejected?

This is truly a case of “the devil in the details,” and below are some of the most commonly missed details that create bottlenecks in the processing of your claims.

  • Incorrect HCPCS codes (updated annually)
  • Incorrect or missing modifiers
  • Failure to include the CMN or DIF on initial claim.
  • Failure to send updated CMN or DIF when there is a change in provider or prescription (such as frequency change, formula change, administration route change, etc.)
  • Incorrect usage of a single date or date range as required
  • Over utilization of units allowed IE: G- Tubes and date spans matching number of kits.

Remember to include relevant codes and modifiers. Here are just a few of the common codes and modifiers you may need.


  • TPN
    • Bill in appropriate gram range
      10-51 grams (B4189), 52-73 grams (B4193), 74-100 grams (B4197), 100+ grams (B4199)
    • Bill supplies in kits
      Admin kit, includes tubing, ext. sets, (B4224) and supply kit, includes alcohol prep pads, gloves,  (B4220)
    • Bill lipids in HCPCS; 10 grams (B4185)
    • Pole (E0776)
    • PUMP, (B9004)
  • Specialty amino acids
  • Enteral Therapy
    • Enteral via pump (B9002) AND Pole E0776
    • Bill formula in HCPCS, 100 cal. units (B4149, B4150, B4152, B4153-B4157, B4161, B4162)
    • Code determined by composition of formula (manufactured, calorie dense, pediatric, diabetic, etc.)
    • Bill supplies in kits
      Pump kit (B4035), gravity kit (B4036), syringe kit (B4034)
  • Medicare allows payment of one G Tube or 3 NG tubes every 90 days


  • BA — ITEM FURNISHED IN CONJUNCTION WITH PARENTERAL ETERNAL NUTRITION (PEN) SERVICES. (EFFECTIVE DATE 1/1/2003)When an IV pole (E0776) is used in conjunction with parenteral nutrition, the BA modifier should be added to the code. Code E0776 is the only code with which the BA modifier may be used.
  • GY: Item or service statutorily excluded or does not meet the definition of any Medicare benefit
  • GA: Item or service that is typically covered but expected to be denied as not reasonable and necessary. ABN and DIF are on file
  • GZ: Item or service that is typically covered but expected to be denied as not reasonable and necessary. DIF is on file, but ABN is not on file.
  • RR: Recurring rental
  • NU: New DME purchase
  • UE: Used DME purchase
  • KH: 1st month rental
  • KI: 2nd – 3rd month rental
  • KJ: 4th -15th month rental

These tips are recommendations based on the experience of Mediware Reimbursement Services’ staff and are subject to change. Check with your compliance officers for audit requirements. Learn how you can simplify your infusion billing with Mediware Reimbursement Services!



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