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MP 1.02.01

Total Parenteral Nutrition and Enteral Nutrition in the Home


Medical Policy
Section
Durable Medical Equipment
Original Policy Date
7/31/96
 

Last Review Status/Date
local policy created /12:2010

Issue
12:2010
Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


Description

Total parenteral nutrition (TPN), also known as parenteral hyperalimentation, is used for patients with medical conditions that impair gastrointestinal absorption to a degree incompatible with life. It is also used for variable periods of time to bolster the nutritional status of severely malnourished patients with medical or surgical conditions and who are unable to benefit from enteral nutritional supplements. TPN involves either peripheral vein catheterization (short-term) or percutaneous transvenous implantation of a central venous catheter (long-term) into the vena cava or right atrium. A nutritionally adequate, sterile, hypertonic solution consisting of glucose (sugar), amino acids (protein), electrolytes (sodium, potassium), vitamins and minerals, and sometimes fats, is administered daily. An infusion pump is generally used to assure a steady flow of the solution on either a continuous (24-hour) or intermittent schedule. If intermittent, a heparin lock device and diluted heparin are used to prevent clotting inside the catheter.

Enteral nutrition (EN) is used for patients with functioning intestinal tracts, but with disorders of the pharynx, esophagus, or stomach that prevent nutrients from reaching the absorbing surfaces in the small intestine. EN involves administering non-sterile liquids directly into the gastrointestinal tract through nasogastric, gastrostomy, or jejunostomy tubes. An infusion pump may be used to assist the flow of liquids. Feedings may be either intermittent or continuous (infused 24 hours a day).


Policy

The following criteria must be met prior to the initial implementation of enteral/parenteral services. In qualifying conditions where enteral nutrition appears appropriate, an attempt must be made to meet the patient's need by enteral nutrition prior to implementing TPN.

PARENTERAL/TOTAL PARENTERAL NUTRITION (TPN)
TPN may be considered medically necessary in the treatment of conditions resulting in impaired intestinal absorption or in obstruction of the GI tract, including but not limited to, any of the following conditions:

  • obstruction of the small or large bowel;
  • short bowel syndrome secondary to extensive small bowel resection;
  • acute pancreatitis of greater than one week's duration;
  • malabsorption due to enterocolic, enterovesical, or enterocutaneous fistulas (TPN being temporary until the fistula is repaired);
  • newborn infants with catastrophic gastrointestinal anomalies such as tracheoesophageal fistula, gastroschisis, omphalocele, or massive intestinal atresia;
  • infants and young children who fail to gain weight due to systemic disease or intestinal insufficiency associated with short bowel syndrome, malabsorption, or chronic idiopathic diarrhea; or
  • patients with prolonged paralytic ileus following major surgery or multiple injuries.

TPN may also be considered medically necessary for the following conditions:

  • patients who have failed to thrive while receiving enteral nutrition;
  • anorexic or bulimic patients whose specific physical abnormalities or weight loss have not stabilized and moved towards correction by enteral nutrition, and who are severely underweight, malnourished or losing weight at a rate that will likely lead to serious medical sequelae. TPN would be used only for the time necessary to stabilize those abnormalities and begin correction. At that time, either enteral nutrition or, if possible, resumption of oral intake is indicated;
  • severe hyperemesis gravidarum; or
  • during chemotherapy, when patients cannot maintain adequate nutrition due to nausea, vomiting or diarrhea. When TPN is used during chemotherapy, the criteria in the policy guidelines do not need to be met.


Benefit Application

BlueCard/National Account Issues

Benefits are usually not provided for nutritional substances when used:
  • to increase protein or caloric intake in addition to the patient’s daily diet;
  • in patients with a stable nutritional status, in whom only short-term parenteral nutrition might be required, i.e., for less than 2 weeks;
  • for routine pre- and/or postoperative care;
  • for over-the-counter enteral nutrition.

Blenderized baby food and regular shelf food used with an enteral system are not eligible for benefits.


Rationale

2010 Update

A literature search for the period of May 2009 through February 2010 did not identify any studies that would alter the current policy statement on enteral and parenteral nutrition. However, the statement on oral nutrition has now been restricted to only those patients with inborn errors of metabolism, clarifying member contract exclusions.

 

Codes

Number

Description

CPT 

36555 – 36571 

Placement of central venous catheter code range 

  36580, 36581, 36582, 36583, 36584, 36585 Replacement of central venous catheter code range

 

43750 

Percutaneous placement of gastrostomy tube 

 

44015 

Tube or needle catheter jejunostomy for enteral alimentation, intra-operative, any method 

ICD-9 Procedure 

38.93 

Venous catheterization, not elsewhere classified 

 

86.07 

Insertion of totally implantable vascular access device 

 

96.6 

Enteral infusion of concentrated nutritional substances 

 

99.15 

Parenteral infusion of concentrated nutritional substances 

ICD-9 Diagnosis 

150.0 – 150.9 

Malignant neoplasm of esophagus code range 

 

197.8 

Secondary malignant neoplasm of other digestive organ 

 

211.0

Benign neoplasm of esophagus 

 

230.1 

Carcinoma in situ of esophagus 

  230.2 Carcinoma in situ of stomach
  235.2 Neoplasm of uncertain behaviour of stomach, intestines, and rectum

 

235.5 

Neoplasm of uncertain behavior of unspecified digestive organs 

 

239.0 

Neoplasm of unspecified nature of digestive system 

 

151.0 – 151.9 

Malignant neoplasm of stomach code range 

 

197.8 

Secondary malignant neoplasm of other digestive organ 

 

239.0 

Neoplasm unspecified nature digestive system 

 

530.3 

Stricture and stenosis of esophagus 

 

537.89 

Other specified disorders of stomach and duodenum 

 

555.0 – 555.9 

Crohn’s disease code range 

 

557.0 

Acute vascular insufficiency of intestine 

 

564.2 

Postgastrectomy syndrome 

 

564.8 

Other specified functional disorders of intestine 

 

569.81 

Fistula of intestine, excluding rectum and anus 

 

579.3 

Other and unspecified postsurgical nonabsorption 

 

579.8 

Other specified intestinal malabsorption 

 

596.1 

Intestinovesical fistula 

 

750.3 

Tracheoesophageal fistula, esophageal atresia and stenosis 

 

750.7 

Other specified anomalies of stomach 

 

751.1 

Atresia and stenosis of small intestine 

 

751.2 

Atresia and stenosis of large intestine, rectum, and anal canal 

 

756.7 

Anomalies of abdominal wall 

 

787.2 

Dysphagia 

 

787.91 

Diarrhea (the policy states “chronic idiopathic diarrhea”; there is no other code for this) 

 

997.4 

Digestive system complication (*this code should be accompanied by a code to identify the specific condition) 

HCPCS 

B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4154, B4157, B4158, B4159, B4160, B4161, B4162 

Enteral formulae code range 

 

B4164, B4168, B4172, B4176, B4178, B4180, B4185, B4189, B4193, B4197, B4216, B4220, B4222, B4224, B5000, B5100, B5200

Parenteral solution code range 

 

B9000 – B9002 

Enteral nutrition infusion pump code range 

 

B9004 – B9006 

Parenteral nutrition infusion pump code range 

  E9998 NOC for enteral supplies
   E9999 NOC for parenteral supplies

 

S9364,S9365, S9366, S9367, S9368 

Home infusion therapy, total parenteral nutrition, per diem code range 

 

S9340, S9341, S9342, S9343

Home therapy, enteral nutrition, per diem code range 

Type of Service 

DME and Supplies 

Place of Service 

Home 


Index

Enteral Nutrition (EN), Home
Home Infusion Therapy (Hyperalimentation), Home
Hyperalimentation, Home
Parenteral Nutrition, Home
Total Parenteral Nutrition (TPN) and Enteral Nutrition (EN), Home
TPN (Total Parenteral Nutrition), Home


Policy History

Date Action Reason
07/31/96 Add to Durable Medical section New policy
04/15/02 Replace policy Policy reviewed without literature review; new review date only
04/29/03 Replace policy Policy no longer scheduled for routine literature review
12/14/05 Replace policy – coding update only CPT and HCPCS coding updated
12/10/10 Replace policy (Local policy) medical necessity indications updated; coding updates


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