Coram is here to help you navigate the complexity of obtaining reimbursement for parenteral nutrition under Medicare part B. The Centers for Medicare and Medicaid Services (CMS) made changes in 2021 to update the guidance on requirements for reimbursement of home parenteral nutrition (PN). The local coverage determination (LCD) published September 5, 2021, and the accompanying policy article state that parenteral nutrition is covered when these criteria are met:
- the treating practitioner has documented that enteral nutrition has been considered and ruled out, tried and been found ineffective, or that enteral nutrition (EN) exacerbates gastrointestinal tract dysfunction
- the beneficiary has “ (a) a condition involving the small intestine and/or its exocrine glands which significantly impairs the absorption of nutrients or (b) disease of the stomach and/or intestine which is a motility disorder and impairs the ability of nutrients to be transported through and absorbed by the gastrointestinal (GI) system”
- the condition is a permanent impairment “of long and indefinite determination”
While the 2021 LCD requirements are not as clearly defined as those of the retired LCD, they allow the prescriber to use detailed progress note documentation to paint the picture of why PN is needed. This is a welcome change from having beneficiaries undergo specific testing based on their diagnosis to demonstrate the need for PN. While objective testing is always preferred to support the need for PN, when not available, the treating practitioner should ask themself these questions and document in a progress note accordingly:
- Why is the patient’s GI tract or exocrine gland not functioning properly resulting in the need for PN support?
- What is the longest time the patient may require PN?
- Why is PN being utilized over tube feeding or oral intake?
- What would happen to the patient if they were not prescribed PN?
Use the checklist below, and consult with your Coram dietitian as needed when transitioning Medicare beneficiaries home on parenteral nutrition:
- Documentation that the patient’s condition involves one of the following:
- a condition involving the small intestine and/or its exocrine glands which significantly impairs the absorption of nutrients
- disease of the stomach and/or intestine which is a motility disorder and impairs the ability of nutrients to be transported through and absorbed by the gastrointestinal (GI) system
- Documentation in the permanent medical record that the condition for which the patient requires PN is of long and indefinite duration
- Objective testing or subjective documentation that supports the clinical need for PN
- ICD-10 codes associated with the need for PN
- PN prescription
- If any component of the PN prescription falls outside the parameters below, or if a specialized product (i.e. hepatic or renal amino acids) is used, additional documentation is required to support the need:
- Calories: 20-35 kcal/kg/day
- Amino acids: 0.8-2.0 g/kg/day
- Dextrose final concentration: ≥ 10%
- Lipids: ≤ 2.5g/kg/day for adults or ≤ 1g/kg/day Pediatric
- Number of days per week PN is infused: 7
Resources:
Centers for Medicare and Medicaid Services. Parenteral Nutrition Local Coverage Determination. LCD ID L38953. Effective date: 9/5/2021. Accessed online December 13, 2021: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=38953
Centers for Medicare and Medicaid Services. Parenteral Nutrition Policy Article. Article ID A58836. Effective date: 9/5/2021. Accessed online December 13, 2021: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=58836&ver=5
Information contained in this article is for general informational purposes only. It is not intended as a substitute for medical advice or independent medical judgment, or to promote the use of any medication that is not clinically appropriate. Patient privacy is important to us. Our employees are trained regarding the appropriate way to handle patients’ private health information.