CAM 10201

Total Parenteral Nutrition and Enteral Nutrition in the Home

Category:Durable Medical Equipment   Last Reviewed:June 2018
Department(s):Medical Affairs   Next Review:June 2019
Original Date:June 2013    

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. TPN involves percutaneous transvenous implantation of a central venous catheter into the vena cava or right atrium. A nutritionally adequate 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 either on 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 a functioning intestinal tract, but with disorders of the pharynx, esophagus or stomach that prevent nutrients from reaching the absorbing surfaces in the small intestine. The patient is at risk of severe malnutrition. 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:
TPN is considered MEDICALLY NECESSARY in the treatment of inanition associated with conditions resulting in impaired intestinal absorption, including such conditions, but not limited to, any of the following:

  • Crohn’s disease
  • Obstruction secondary to stricture or neoplasm of the esophagus or stomach; loss of the swallowing mechanism due to a central nervous system disorder, where the risk of aspiration is great
  • Short bowel syndrome secondary to massive small bowel resection
  • Malabsorption due to enterocolic, enterovesical or enterocutaneous fistulas (TPN being temporary until the fistula is repaired)
  • Motility disorder (pseudo-obstruction)
  • Newborn infants with catastrophic gastrointestinal anomalies such as tracheoesophageal fistula, gastroschisis, omphalocele or massive intestinal atresia
  • Infants and young children who fail to thrive due to systemic disease or secondarily to intestinal insufficiency associated with short bowel syndrome, malabsorption or chronic idiopathic diarrhea
  • Patients with prolonged paralytic ileus following major surgery or multiple injuries

All of the following criteria must be met before the initial implementation of TPN:

  • The patient must be in a stage of wasting as indicative of the following:
  • Weight is significantly less than normal body weight for a patient’s height and age in comparison with pre-illness weight.
  • Serum albumin is less than 3.0 gm.
  • Blood urea nitrogen (BUN) is below 10 mg (but this is not a good marker in patients receiving dialysis due to protein catabolism).
  • The patient can receive no more than 30 percent of his/her caloric needs orally or the patient cannot benefit from tube feedings as a result of a malabsorptive disorder.

Enteral nutrition is considered MEDICALLY NECESSARY under the following conditions:

  • An anatomical inability to swallow exists, due to, for example, head and neck cancer or an obstructing tumor or stricture of the esophagus or stomach.
  • Central nervous system disease leading to sufficient interference with the neuromuscular coordination of chewing and swallowing that a risk of aspiration exists.

Policy Guidelines:
In general, a daily caloric intake of 2,000-2,200 calories is sufficient to maintain body weight. If 750 calories per day or less are being administered by TPN or EN, they are considered supplemental, and benefits should be denied as NOT MEDICALLY NECESSARY.

Nutrients and their manner of administration for both TPN and EN must be specifically ordered by a physician and be preapproved on an individual consideration basis.

Approved TPN or EN services (those that require a physician’s prescription) may include, but are not limited to, the following:

  • Cost of nutrients and solutions, cost of rental or purchase of an infusion pump and heparin lock
  • Supplies and equipment necessary for the proper functioning and effective use of a TPN or EN system (e.g., catheters, dressings, IV stand, needles, filters, extension tubing and concentrated nutrients)
  • Home visits by a physician
  • Home visits by a registered nurse (RN) or licensed practical nurse (LPN) under the order and supervision of a physician, which meet guidelines for home care benefits. Skilled nursing services may include injection of drugs (IV or IM) and drawing of blood

Benefit Application:
BlueCard®/National Account Issues

Benefits may be provided for placement of central venous catheters and gastrostomy or jejunostomy feeding tubes when policy guidelines have been met for TPN or EN.

The total cost of renting equipment should not exceed the purchase cost of the equipment.

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 two 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:
A search of the literature was completed through the MEDLINE database for the period of January 1992 through April 14, 1995. The search strategy focused on references containing the following medical subject headings:

  • Enteral Nutrition
  • Parenteral, Total, Home (includes Hyperalimentation)

Research was limited to English-language journals on humans.

Coding Section

Codes  Number  Description 
CPT 36555-36571  Placement 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) 
  151.0-151.9 Malignant neoplasm of stomach (code range) 
  197.8

Secondary malignant neoplasm of other digestive organ 

  211.1 Benign neoplasm of esophagus
  230.1

Carcinoma in situ of esophagus 

  230.2 Carcinoma in situ of stomach
  235.2 Neoplasm of uncertain behavior of stomach, intestines, and rectum 
  235.5

Neoplasm of uncertain behavior of unspecified digestive organs 

  239.0 Neoplasm of unspecified nature of digestive system 
  530.3 Stricture and stenosis of esophagus
  537.4

Fistula of stomach or duodenum

  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
  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 

  756.70

Anomalies of abdominal wall 

  787.20

Dysphagia 

  787.91

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

  997.40 Digestive system complication (*this code should be accompanied by a code to identify the specific condition)
HCPCS B4102-B4162 Enteral formulae code range
  B4164-B5200 Parenteral solution code range
  B9000-B9002 Enteral nutrition infusion pump code range
  B9004-B9006  Parenteral nutrition infusion pump code range 
  S9364-S9368  Home infusion therapy, total parenteral nutrition, per diem code range  
  S9340-S9343  Home therapy, enteral nutrition, per diem code range  
ICD-10-CM (effective 10/01/15)  C15.3-C15.9  Malignant neoplasm of esophagus 
  C16.0-C16.9

Malignant neoplasm of stomach 

  C78.7-C78.89 Secondary malignant neoplasm of other digestive organs 
  D00.1 Carcinoma in situ of esophagus 
  D00.2  Carcinoma in situ of stomach 
  D13.1  Benign neoplasm of stomach 
  D37.1-D37.5 

Neoplasm of uncertain behavior of stomach, intestines, and rectum 

  D37.8, D37.9 

Neoplasm of uncertain behavior of other digestive organs 

  D49.0 

Neoplasm of unspecified behavior of digestive system 

  K22.2

Esophageal obstruction 

  K31.6  Fistula of stomach and duodenum 
  K31.7   Polyp of stomach and duodenum
  K31.89  Other diseases of stomach and duodenum 
  K50.00-K50.9

Crohn's disease of small intestine without complications 

  K52.2 

Allergic and dietetic gastroenteritis and colitis 

  K52.89  Other specified noninfective gastroenteritis and colitis 
  K55.0  Acute vascular disorders of intestine 
  K63.2  Fistula of intestine 
  K90.4 

Malabsorption due to intolerance, not elsewhere classified 

  K90.89  Other intestinal malabsorption 
  K90.9  Intestinal malabsorption, unspecified 
  K91.1  Postgastric surgery syndromes 
  K91.2  Postsurgical malabsorption, not elsewhere classified 
  K91.89  Other intraoperative complications and Postprocedural complications of digestive system 
  N32.1  Vesicointestinal fistula 
  Q39.0-Q39.4  Congenital malformation of esophagus 
  Q39.5  Congenital diatation of esophagus 
  Q40.2 Other specified congenital malformations of stomach 
  Q41.0-Q41.9  Congenital absence, atresia and stenosis of small intestine 
  Q42.0-Q42.9  Congenital absence, atresia and stenosis of large intestine 
  Q79.59 

Other congenital malformations of abdominal wall 

  R13.10-R13.19 

Dysphagia 

  R19.7 

Diarrhea 

Type of Service DME and Supplies 

 

 Place of Service Home 

 

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines. 

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2014 Forward     

06/08/2018 

Annual review, no change to policy intent.

06/05/2017 

Annual review, no change to policy intent. Updating coding. 

05/12/2017 

Corrected review date. No other change

06/01/2016 

Annual review, no change to policy intent.

06/08/2015 

Annual review, policy verbiage changed: phosphorous requirement has been removed and serum albumin requirement has been changed to 3.0. Added coding. 

06/11/2014

Annual Review. No change to policy intent.

 


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