Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Total Parenteral Nutrition (TPN) / Intradialytic Parenteral Nutrition (IDPN) / Intraperitoneal Parenteral Nutrition (IPN)

Policy #:08.00.17g

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

TOTAL PARENTERAL NUTRITION

MEDICALLY NECESSARY
Total parenteral nutrition (TPN) is considered medically necessary and, therefore, covered when both of the following indications are met:
  • The individual has a permanently impaired* (non-functioning) gastrointestinal tract resulting in insufficient absorption of nutrients to maintain adequate strength and weight.
  • The individual failed a tube trial of enteral nutrition through an enteral feeding tube by meeting at least one of the following:
    • A concerted effort was made to place an enteral feeding tube or is contraindicated.
    • A trial with enteral nutrition was made, with appropriate attention to dilution, rate, and alternative formulas, to address side effects of diarrhea.

AND EITHER:
  • The individual meets one of the following conditions, which are considered to be severe enough that the individual would not be able to maintain weight and strength on only oral intake or through an enteral feeding tube:
    • The individual has undergone a recent (within the past 3 months) massive small bowel resection leaving less than or equal to 5 feet of small bowel beyond the ligament of Treitz, or
    • The individual has a short bowel syndrome that is severe enough that the individual has net gastrointestinal fluid and electrolyte malabsorption such that on an oral intake of 2.5-3 liters/day the enteral losses exceed 50% of the oral/enteral intake and the urine output is less than 1 liter/day, or
    • The individual requires bowel rest for at least 3 months and is receiving intravenously 20-35 cal/kg/day for treatment of symptomatic pancreatitis with/without pancreatic pseudocyst, severe exacerbation of regional enteritis, or a proximal enterocutaneous fistula where tube feeding distal to the fistula isn't possible, or
    • The individual has complete mechanical small bowel obstruction where surgery is not an option, or
    • The individual is significantly malnourished (10% weight loss over 3 months or less and serum albumin less than or equal to 3.4 gm/dl) and has very severe fat malabsorption (fecal fat exceeds 50% of oral/enteral intake on a diet of at least 50 gm of fat/day as measured by a standard 72 hour fecal fat test), or
    • The individual is significantly malnourished (10% weight loss over 3 months or less and serum albumin less than or equal to 3.4 gm/dl) and has a severe motility disturbance of the small intestine and/or stomach which is **unresponsive to prokinetic medication and is demonstrated by either:
      • Scintigraphically (solid meal gastric emptying study demonstrates that the isotope fails to reach the right colon by 6 hours following ingestion), or
      • Radiographically (barium or radiopaque pellets fail to reach the right colon by 6 hours following administration). These studies must be performed when the individual is not acutely ill and is not on any medication which would decrease bowel motility.
    • The individual has severe Hyperemesis Gravidarum.

OR:
  • The individual meets All of the following criteria:
    • Maintenance of weight and strength commensurate with the individual’s overall health status requires intravenous nutrition and is not possible by utilizing both of the following approaches:
      • Modifying the nutrient composition of the enteral diet (e.g., lactose free, gluten free, low in long chain triglycerides, substitution with medium chain triglycerides, provision of protein as peptides or amino acids, etc.,) and
      • Utilizing pharmacologic means to treat the etiology of the malabsorption (e.g., pancreatic enzymes or bile salts, broad spectrum antibiotics for bacterial overgrowth, prokinetic medication for reduced motility, etc.)
    • The individual is malnourished (10% weight loss over 3 months or less and serum albumin less than or equal to 3.4 gm/dl).
    • A disease and clinical condition has been documented as being present and it has not responded to altering the manner of delivery of appropriate nutrients (e.g., slow infusion of nutrients through an enteral feeding tube with the tip located in the stomach or jejunum).

*A permanent impairment is defined as a permanence that does not require a determination that there is no possibility that the individual's condition may improve sometime in the future. If the judgment of the professional provider, substantiated in the medical record, is that the condition is of long and indefinite duration (ordinarily at least 3 months), the test of permanence is considered met.

**Unresponsiveness to prokinetic medication is defined as the presence of daily symptoms of nausea and vomiting while taking maximal doses.

NOT MEDICALLY NECESSARY
TPN is considered not medically necessary and, therefore, not covered for individuals with a functioning gastrointestinal tract whose need for parenteral nutrition is only required because of any of the following conditions, such as, but not limited to:
  • Swallowing disorder
  • Temporary defect in gastric emptying, such as a metabolic or electrolyte disorder
  • Psychological disorder impairing food intake, such as depression
  • Metabolic disorder inducing anorexia, such as cancer
  • Physical disorder impairing food intake, such as the dyspnea of severe pulmonary or cardiac disease
  • Side effect of a medication
  • Renal failure and/or dialysis

SPECIAL FORMULATIONS OF PARENTERAL NUTRITION

Parenteral nutrition solutions containing little or no amino acids and/or carbohydrates is considered medically necessary and, therefore, covered for any of the following indications:
  • The individual has undergone recent (within the past 3 months) massive small bowl resection leaving less than or equal to 5 feet of small bowel beyond the ligament of Treitz, or
  • The individual has a short bowel syndrome that is severe enough that the individual has net gastrointestinal fluid and electrolyte malabsorption such that on an oral intake of 2.5 to 3 liter/day the enteral losses exceed 50% of the oral/enteral intake, and the urine output is less than 1/liter/day, or
  • The individual has complete mechanical small bowel obstruction where surgery is not an option.

INTRADIALYTIC PARENTERAL NUTRITION

MEDICALLY NECESSARY
Intradialytic parenteral nutrition (IDPN) is considered medically necessary and, therefore, covered for either of the following:
  • When it is infused as an alternative to a regularly scheduled regimen of TPN in individuals who meet the medical necessity criteria for TPN, or
  • In individuals with a functional gastrointestinal tract when all of the following criteria are met:
    • The individual has a documented comprehensive nutritional assessment and dietary counseling
    • In spite of enteral nutrition via tube feeding, or adequate oral nutrition, the individual has evidence of protein or energy malnutrition as defined by any of the following:
      • Evidence of protein intake <1.2g/Kg or calories<25 Kcal/Kg
      • Evidence of weight loss 10-20% of usual body weight within 3-6 months
      • Serum Albumin Levels <3.4 g/l (3 months average)
    • The individual has evidence of adequate dialysis therapy
    Note: After an initial 3-month trial, continued coverage will depend on the degree of improvement in nutritional status, taking into consideration the individual’s serum albumin levels.

INTRAPERITONEAL NUTRITION

MEDICALLY NECESSARY
Intraperitoneal nutrition (IPN) is considered medically necessary and, therefore, covered when all of the following criteria are met:
  • The individual has a documented comprehensive nutritional assessment and dietary counseling
  • In spite of enteral nutrition via tube feeding, or adequate oral nutrition, the individual has evidence of protein or energy malnutrition as defined by any of the following:
    • Evidence of protein intake <1.2g/Kg or calories<25 Kcal/Kg
    • Evidence of weight loss 10-20% of usual body weight within 3-6 months
    • Serum albumin Levels <3.4 g/l (3 months average)
  • The individual has evidence of adequate dialysis therapy

ASSOCIATED SERVICES

When an infusion therapy service is covered, all associated services (e.g., solutions, additives, equipment and/or supplies, nursing) are considered covered and eligible for reimbursement.

When an infusion therapy service is not covered, all associated services (e.g., solutions, equipment and/or supplies, nursing) are considered not covered, and, therefore, not eligible for reimbursement.

REQUIRED DOCUMENTATION

NON-FUNCTIONING GASTROINTESTINAL TRACT
A total caloric daily intake (parenteral, enteral and oral) of 20-35 cal/kg/day is considered sufficient to achieve or maintain appropriate body weight. The ordering professional provider must document in the medical record the medical necessity for a caloric intake outside this range for the individual.
  • The ordering professional provider must document the medical necessity for protein orders outside of the range of 0.8-1.5 gm/kg/day, dextrose concentration less than 10%, or lipid use greater than 1500 grams (150 units of service of code B4185) per month.

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation:

PRESCRIPTION (ORDER) REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES
The durable medical equipment (DME) supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately seven days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately five days before the individual would exhaust their on-hand supply.

If required documentation is not available on file to support a claim at the time of an audit or record request, the durable medical equipment (DME) supplier may be required to reimburse the Company for overpayments.
Guidelines

AN ENTERAL FEEDING TUBE TRIAL:
  • For gastroparesis, tube placement must be post-pylorus, preferably in the jejunum.

EXAMPLES OF A FAILED ENTERAL FEEDING TUBE TRIAL:
  • An individual who has had documented placement of a tube in the post-pyloric area continues to have problems with vomiting, and, on radiographic recheck, the tube has returned to the stomach.
  • After an attempt of sufficient time (5-6 hours) to get a tube into the jejunum, the tube does not progress and remains in the stomach or duodenum.
  • An attempt of enteral tube feeding with a very slow drip was made that was initially well-tolerated but then vomiting occurred when the rate was increased.
  • After placement of the tube in the jejunum and 1-2 days of enteral tube feeding, the individual has vomiting and distension.
  • A tube is placed appropriately and remains in place. Enteral nutrition is initiated and the concentration and rate are increased gradually. Over the course of 3-4 weeks, attempts to increase the rate and/or concentration and/or to alter the formula to reach the targeted intake are unsuccessful, with increase in diarrhea, bloating or other limiting symptoms, and the individual is unable to meet the needed nutritional goals (stabilize at desired weight or gain weight as needed).

CONDITIONS REQUIRING A FAILED ENTERAL TUBE FEEDING TRIAL:

The following are some examples of moderate abnormalities which would require a failed trial of enteral tube feeding before parenteral nutrition would be covered:
  • Moderate fat malabsorption -- fecal fat exceeds 25% of oral/enteral intake on a diet of at least 50 gm of fat/day as measured by a standard 72 hour fecal fat test.
  • Diagnosis of malabsorption with objective confirmation by methods other than 72-hour fecal fat test (e.g., Sudan stain of stool, d-xylose test, etc.)
  • Gastroparesis which has been demonstrated (a) radiographically or scintigraphically as described above with the isotope or pellets failing to reach the jejunum in 3-6 hours, or (b) by manometric motility studies with results consistent with an abnormal gastric emptying, and which is unresponsive to prokinetic medication
  • A small bowel motility disturbance which is unresponsive to prokinetic medication, demonstrated with a gastric to right colon transit time between 3-6 hours.
  • Small bowel resection leaving greater than 5 feet of small bowel beyond the ligament of Treitz.
  • Short bowel syndrome which is not severe.
  • Mild to moderate exacerbation of regional enteritis, or an enterocutaneous fistula.
  • Partial mechanical small bowel obstruction where surgery is not an option.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, total parenteral nutrition (TPN), intradialytic parenteral nutrition (IDPN), and intraperitoneal nutrition (IPN) are covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

However, services that are identified in this policy as not medically necessary are not eligible for coverage or reimbursement by the Company.

Description

TOTAL PARENTERAL NUTRITION

Total parenteral nutrition (TPN), also known as parenteral hyperalimentation, involves the delivery of micronutrients and macronutrients via infusion to an individual with complex nutritional needs. TPN consists of the optimal levels of glucose, amino acids, electrolytes, vitamins, minerals, and fats; the concentration of each component is calculated for the individual's specific metabolic need. TPN bolsters and/or maintains the nutritional status of moderately to severely malnourished individuals who have medical or surgical conditions such as gastrointestinal (GI) anomalies or impaired intestinal absorption or motility.

For individuals who have moderate GI abnormalities (e.g., malabsorption disorders), TPN is typically instituted when enteral nutrition via a nasogastric, gastrostomy, or jejunostomy tube has failed. TPN may be part of the treatment plan for individuals who have severe pathology of the digestive system that does not allow for the absorption of sufficient nutrients to maintain weight and strength. Highly concentrated parenteral products are available for individuals who have fluid restrictions.

TPN is administered through a central intravenous line access or a peripherally inserted central catheter (PICC). An infusion pump regulates the flow of the solution on either a continuous (24-hour) or intermittent schedule.

INTRADIALYTIC PARENTERAL NUTRITION AND INTRAPERITONEAL NUTRITION

The indications for intradialytic parenteral nutrition (IDPN) and intraperitoneal parenteral nutrition (IPN) are similar to those for TPN. IDPN refers to the delivery of micronutrients and macronutrients to individuals who have complex nutritional needs during hemodialysis. It is the infusion of supplemental nutrition (composed of dextrose, amino acids, and sometimes, lipids) during dialysis in individuals with protein calorie malnutrition. This process typically begins 30 minutes after dialysis is initiated, and is continued for remainder of the dialysis session. In peritoneal dialysis, also referred to as intraperitoneal parenteral nutrition (IPPN) or intraperitoneal nutrition (IPN), the infusion of nutrition is done through the peritoneal cavity.

Protein energy wasting (PEW) is a common condition in individuals with end-stage renal disease (ESRD). While the nutritional status assessment in individuals with ESRD is multifactoral, measurement of serum albumin levels is a clinically practiced method in evaluation of protein calorie malnutrition, which is associated with increased morbidity and mortality. Although albumin concentrations can be affected by multiple other disease states, these levels are considered to be a clinically relevant measurement for assessing nutritional status by the National Kidney Foundation (NKF)/Kidney Disease Outcomes Quality Initiative (KDOQI) (2000). The KDOQI guidelines recommend dietary protein intake of no less than 1.2 g/kg in individuals undergoing hemodialysis, and no less than 1.3 g/kg in individuals undergoing peritoneal dialysis. Generally, serum albumin concentration of 3.5 g/dL to 5.5 g/dL are considered normal; although the KDOQI guidelines recommend a serum albumin concentration of 4.0 g/dL. Serum albumin concentrations below 3.5 g/dL are associated with twice the mortality rate of that of concentrations greater than or equal to 4.0 g/dL, while concentration below 2.5 g/dL are associated with a 10-fold increase in mortality.

Available published peer-reviewed medical literature on IDPN consists of poorly designed randomized controlled trials (RCTs), as well as case series which do not control for critical variables common in individuals with chronic kidney disease. In a 2010 systematic review (Sigrist, et al), the authors concluded that the three available RCTs published to date were insufficient to demonstrate net benefit or net harm associated with IDPN and that further clinical trials are warranted to demonstrate net benefits in health outcomes. To date, there are no studies addressing IPN in individuals undergoing peritoneal dialysis.

As of May 2016, there are no ongoing clinical trials addressing IDPN, and two completed clinical trials (NCT00501956, NCT00244075) on www.clinicaltrials.gov. Results of the completed trials have not been published.

A general consensus among professional societies regarding treatment options, net health outcomes, and patient selection to address malnutrition in individuals with chronic kidney disease is varied.
The National Institute of Health and Clinical Excellence (NICE) published guidelines in 2006 to address nutritional support in adults and states nutritional support should be considered in the following populations:
  • Malnourished individuals as defined by any of the following:
    • A BMI of less than 18.5 kg/m2
    • Unintentional weight loss greater than 10% within the last 3-6 months
    • A BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within the last 3-6 months
  • Individuals at risk of malnutrition as defined by any of the following:
    • Have poor absorptive capacity and/or have high nutrient losses and/or have increased nutritional needs from causes such as catabolism
  • Have eaten little or nothing for more than five days and/or are likely to eat little or nothing for the next five days or longer

The NICE guidelines also state parenteral nutrition should only be considered in malnourished individuals or individuals at risk of malnutrition if they meet either of the following criteria:
  • Inadequate or unsafe oral and/or enteral nutritional intake
  • A non-functional, inaccessible, or perforated (leaking) gastrointestinal tract

The National Kidney Foundation/Kidney Disease Outcomes Quality Initiative (KDOQI), published clinical practice guidelines for nutrition in children with chronic kidney disease (2008). They state that a trial of IDPN should be considered in malnourished children, as defined by BMI-for-height-age <5th percentile, on hemodialysis, who do not meet adequate nutritional intake through oral and tube feeding.

Guidelines by the German Association of Nutritional Medicine on Parenteral Nutrition recommend use of IDPN only when modifiable causes of malnutrition are excluded, and enhanced oral or enteral supply is unsuccessful or cannot be carried out.

A position statement published by the American Gastroenterological Association in 1995 states enteral nutrition should be considered for individuals who cannot or will not eat, and who have a functional gastrointestinal tract and a safe method of access. Furthermore, if there are no contraindications, and access can be obtained safely (and oral intake is not possible), preference should be given to enteral feeding over parenteral therapy. An additional statement published in 2001 on parenteral nutrition states, in general, that parenteral nutrition is indicated to avoid malnutrition in individuals who cannot obtain adequate nutrients by oral or enteral routes.

Overall, the evidence of efficacy of intradialytic parenteral nutrition in individuals with chronic kidney disease is limited. Although the available published peer-reviewed scientific literature is not robust, it suggests that IDPN therapy may be beneficial in a subset of the population in whom both oral and enteral nutrition have continually failed to provide patients' nutritional needs. Additional well-designed prospective studies, with outcomes in long-term data, survival, and quality of life are warranted.
References


American Gastroenterological Association. American Gastroenterological Association medical position statement: Guidelines for the use of enteral nutrition. Gastroenterology. 1995;108:1280-301

American Gastroenterological Association. American Gastroenterological Association medical position statement: parenteral nutrition. Gastroenterology. 2001;121(4):966-969.

American Society for Parenteral and Enteral Nutrition (ASPEN) (2010). Clinical Guidelines: Nutrition support in adults in acute and chronic renal failure. Available at: http://pen.sagepub.com/content/34/4/366.full.pdf. Accessed September 24, 2018.

Cano NJ, Fouque D, Roth H, et al. Intradialytic parenteral nutrition does not improve survival in malnourished hemodialysis patients: a 2-year multicenter, prospective, randomized study. J AM Soc Nephrol. 2007;18(9):2583-91.

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 15: Covered Medical and Other Health Services. [CMS Website]. 120 - Prosthetic Devices (Rev. 241, 02-02-18) Available at:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf . Accessed September 24, 2018.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 180.2: Enteral and parenteral nutritional therapy. [CMS Web site]. 07/11/84. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=242&ncdver=1&DocID=180.2&bc=gAAAABAAAAAA&. Accessed September 24, 2018.

Company Benefit Contracts.

Druml W, Kierdorf HP; Working group for developing the guidelines for parenteral nutrition of The German Association for Nutritional Medicine. Parenteral nutrition in patients with renal failure - Guidelines on Parenteral Nutrition, Chapter 17. Ger Med Sci. 2009;7:Doc11.

Herrell HE. Nausea and vomiting of pregnancy. Am Fam Physician.2014 ;89(12):965-70.

Ikizler TA. Parenteral nutrition offers no benefit over oral suplementation in malnourished hemodialysis patients. Nat Clin Pract Nephrol. 2008;4(2):76-7.

KDOQI Clinical Practice Guideline for Nutrition in Children with CKD: 2008 update. Executive summary. Am J Kidney Dis. 2009; 53(3 Suppl 2):S11-104. Available at: https://www.kidney.org/sites/default/files/docs/kdoqi2000nutritiongl.pdf . Accessed September 24, 2018.

Korzets A, Azoulay O, Ori Y, et al. The use of intradialytic parenteral nutrition in acutely ill haemodialysed patients. J Ren Care. 2008;34(1):14-8.

Marsen TA, Beer J, Mann H, et al. Intradialytic parenteral nutrition in maintenance hemodialysis patients suffering from protein-energy wasting. Results of a multicenter, open, prospective, randomized trial. Clin Nutr. Feb 2017;36(1):107-117.

National Institute for Health and Clinical Excellence (NICE). Clinical Guideline 32 Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. February 2006. Available at: https://www.nice.org.uk/guidance/cg32. Accessed September 24, 2018.

National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI). Clinical Practice Guidelines for Nutrition in Chronic Renal Failure. 2000. Available at: https://www.kidney.org/sites/default/files/docs/kdoqi2000nutritiongl.pdf . Accessed September 24, 2018.

Noridian. Local Coverage Determination (LCD). L33798: Parenteral Nutrition. Original effective: 10/01/2015. Revised effective: 01/01/17. Available at:
https://med.noridianmedicare.com/documents/2230703/7218263/Parenteral+Nutrition+LCD+and+PA/1b7429bc-6645-41dc-8167-88a15ffed946. Accessed September 24, 2018.

Noridian. Parenteral Nutrition - Policy Article - (A52515) Original effective: 10/01/2015. Revised Effective: 01/01/2017. Available at: https://med.noridianmedicare.com/documents/2230703/7218263/Parenteral+Nutrition+LCD+and+PA/1b7429bc-6645-41dc-8167-88a15ffed946. Accessed September 24, 2018.

Sigrist MK, Levin A, Tejani AM. Systematic review of evidence for the use of intradialytic parenteral nutrition in malnourished hemodialysis patients. J Ren Nutr. 2010;20(1):1-7. Epub 2009 Sep 27.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)



THE FOLLOWING CODES ARE USED TO REPRESENT HOME INFUSION THERAPY:

S9364 Home infusion therapy, total parenteral nutrition (TPN); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem (do not use with home infusion codes S9365-S9368 using daily volume scales)

S9365 Home infusion therapy, total parenteral nutrition (TPN); 1 liter per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem

S9366 Home infusion therapy, total parenteral nutrition (TPN); more than 1 liter but no more than 2 liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem

S9367 Home infusion therapy, total parenteral nutrition (TPN); more than 2 liters but no more than 3 liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem

S9368 Home infusion therapy, total parenteral nutrition (TPN); more than 3 liters per day, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs other than in standard formula and nursing visits coded separately), per diem

THE FOLLOWING CODES ARE USED TO REPRESENT PARENTERAL NUTRITION SOLUTIONS:

B4164 Parenteral nutrition solution; carbohydrates (dextrose), 50 % or less (500 ml = 1 unit) - home mix

B4168 Parenteral nutrition solution; amino acid, 3.5 %, (500 ml = 1 unit) - home mix

B4172 Parenteral nutrition solution; amino acid, 5.5 % through 7 %, (500 ml = 1 unit) - home mix

B4176 Parenteral nutrition solution; amino acid, 7 % through 8.5 %, (500 ml = 1 unit) - home mix

B4178 Parenteral nutrition solution; amino acid, greater than 8.5 % (500 ml = 1 unit) - home mix

B4180 Parenteral nutrition solution; carbohydrates (dextrose), greater than 50 % (500 ml = 1 unit) - home mix

B4185 Parenteral nutrition solution, per 10 grams lipids

B4189 Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 10 to 51 grams of protein-premix

B4193 Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, 52 to 73 grams of protein-premix

B4197 Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength 74 to 100 grams of protein-premix

B4199 Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, over 100 grams of protein - premix

B4216 Parenteral nutrition; additives (vitamins, trace elements, heparin, electrolytes) - home mix, per day

THE FOLLOWING CODES ARE USED TO REPRESENT SPECIALIZED NUTRITION SOLUTIONS:

B5000 Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, renal-aminosyn-rf, nephramine, renamine-premix

B5100 Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, hepatic, hepatamine-premix

B5200 Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, stress-branch chain amino acids-freamine-hbc-premix

THE FOLLOWING CODE IS USED TO REPRESENT PARENTERAL NUTRITION SOLUTIONS CONTAINING LESS THAN 10 GRAMS OF PROTEIN PER DAY:

B9999 NOC for parenteral supplies

THE FOLLOWING CODES ARE USED TO REPRESENT PARENTERAL NUTRITION EQUIPMENT AND SUPPLIES:

B4220 Parenteral nutrition supply kit; premix, per day

B4222 Parenteral nutrition supply kit; home mix, per day

B4224 Parenteral nutrition administration kit, per day

B9004 Parenteral nutrition infusion pump, portable

B9006 Parenteral nutrition infusion pump, stationary



Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

08.00.17g
11/21/2018This policy became effective 9/21/2016. It has been reviewed and reissued to communicate the Company’s continuing position on Total Parenteral Nutrition (TPN) / Intradialytic Parenteral Nutrition (IDPN) / Intraperitoneal Parenteral Nutrition (IPN).


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 09/21/2016
Version Issued Date: 09/21/2016
Version Reissued Date: 11/21/2018

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.