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Printer Friendly Version Parenteral (PEN) and Enteral (EN) Nutrition Support in the Home

Parenteral (PEN) and Enteral (EN) Nutrition Support in the Home

DESCRIPTION

Parenteral nutritional support (PEN), 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. PEN 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 support (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/day).

POLICY

Participating providers are required to follow the American Dietetic Association Medical Nutrition Therapy Protocols for Parenteral and Enteral Feeding Support.

Parenteral feeding support (PEN) in the home is considered medically necessary in the treatment of inanition associated with conditions resulting in impaired intestinal absorption, including the following conditions, but not limited to, any of the conditions listed in the "Code Reference" section.

Crohn's disease;
Obstruction secondary to stricture or neoplasm of the esophagus, stomach, or small intestine;
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 (PEN 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;
Other conditions such as hyperemesis gravidarum and pancreatitis.

The following criteria must be met prior to the initial implementation of parenteral feeding support (PEN):

The patient can receive no more than 30% of his/her caloric needs orally or the patient cannot benefit from enteral feedings.
The patient may be in a stage of wasting as indicated by the following:

Unintentional weight loss greater than 5% over 1 month or 10% over 6 months from usual body weight; adjust for body part amputation;
Serum albumin is less than 3.4 gm;
BUN is below 10 mg (this is not a good marker in patients receiving dialysis due to protein catabolism);
Phosphorus level is less than 2.5 mg (normal phosphorus is 3 - 4.5 mg)

Enteral feeding support (EN) in the home 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.

If 25% of estimated calories needed per day or less are being administered by PEN or EN, they are considered supplemental and benefits will be denied as not medically necessary.

Benefits will not be 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 feeding support might be required; i.e., for less than 2 weeks;
for routine pre- and/or postoperative care;
for over-the-counter nutritional supplements or enteral nutrition, this generally includes any product that can be obtained at a wholesale club, pharmacy or over the internet that does not require a written provider prescription (medical nutritionals, while should be used under the direction of a provider, usually DO NOT require a prescription and therefore are not covered)

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

Nutrients and their method of administration for both PEN and EN must be specifically ordered by a physician.

Approved PEN 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 PEN or EN system (e.g., catheters, dressings, IV stand, needles, filters, extension tubing, bags 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.
home visits by a licensed, registered dietitian according to the American Dietetic Association Medical Nutrition Therapy Protocols for Parenteral and Enteral Feeding Support.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

Global allowances for PEN and EN feeding support in the home include nursing services, cost of supplies, clinical pharmacy service, dietitian monitoring, supply delivery and administrative overhead.

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

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

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

POLICY HISTORY

6/1994: Approved by Medical Policy Advisory Committee (MPAC) as Home Hyperalimentation

5/1999: MPAC reviewed, updated and renamed policy, HCPCS T0015, T0030, T0045, T0060 added

3/5/2002: Prior authorization deleted

3/12/2002: New 2002 HCPCS B4164, B4168, B4172, B4176, B4178, B4180, B4184, B4186, B4189, B4193, B4197, B4199, B4216, B4220, B4222, B4224, B5000, B5100, B5200, B9000, B9002, B9004, B9006, B9998, B9999 added

3/19/2002: Fifth digit required for 643.0X, review on an "Individual basis" for 577.0 and 643.0X has been deleted

5/2/2002: Type of Service and Place of Service deleted

5/28/2002: Code Reference section updated, CPT 99560, 99561, 99562 added, HCPCS B4081, B4082, B4083, B4086, S5520, S5522, S9123, S9124, S9340, S9341, S9342, S9343, S9364-S9368, S9374-S9379, S9524 added

8/26/2003: Code Reference section updated, CPT code 97802, 99341-99350, 99601, 99602 added, CPT code 99560, 99561, 99562 deletion dated of 6/30/2003 added, ICD-9 procedure code 99.15 added, ICD-9 diagnosis codes 530.3, 537.89, 560.9, 577.0, 643.0X, 750.3, 751.2, 756.79 listed separately, 643.0X fifth digit added, ICD-9 diagnosis code 141.0-141.9, 150.0-150.9, 151.0-151.9, 195.0, 197.8, 198.89, 210.0-210.9, 211.0, 211.1. 230.0-230.2, 232.4, 234.8, 235.0-235.2, 235.5, 238.8, 239.0, 239.8, 261, 783.21 added, HCPCS B4034, B4035, B4036, B4081, B4082, B4083, B4086, B4164, B4168, B4172, B4176, B4178, B4180, B4184, B4186, B4189, B4193, B4197, B4199, B4216, B4220, B4222, B4224, B5000, B5100, B5200, B9000, B9002, B9004, B9006, B9998, B9999, S9123, S9124, S9374-S9379, S9524 deleted, HCPCS S9364-S9368 listed separately, HCPCS G0108, G0109, S5517, S5518 added, HCPCS H0201, H0300, H0301, H0600 BCBSMS deletion date of 9/30/2003 added, HCPCS S5520, S5522 description revised, HCPCS T0015, T0030, T0045, T0060 “BCBSMS deletion date of 9/30/2003, see codes G0108-G0109 and 97802” added, Notes “**B4150 is the code used for all categories. Processors will recode any codes from B4151-B4156 to B4150” and “B4081-B4086 are included in the global service H0300 or H0301. B4081-B4086 will be bundled with either H0300 or H0301 on the claim” deleted, conditions moved from "Code Reference" section to "Policy" section

3/23/2005: Code Reference section reviewed, CPT code 97803, 97804 added covered codes, CPT 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350 description revised, CPT 99560, 99561, 99562 deleted, HCPCS B4102, B4103, B4104, B4157, B4158, B4159, B4160, B4161, B4162, B4164, B4168, B4172, B4176, B4178, B4180, B4184, B4186, B4189, B4193, B4197, B4199, B4216, B5000, B5100, B5200 added covered codes, HCPCS B4151, B4156 description revised and deletion date of 12/31/2004 added, HCPCS B4152, B4153, B4154, B4155 description revised, HCPCS T0015, T0030, T0045, T0060 deleted, non-covered codes table added, HCPCS B4149 added non-covered codes

3/9/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy.

10/23/2006: Policy reviewed, no changes

9/20/2007: Code Reference section updated. ICD-9 2007 revisions added to policy

9/15/2008: Code reference section updated per the annual ICD-9 updates effective 10-1-2008

9/28/2009: Code reference section updated. New ICD-9 diagnosis codes 239.81, 239.89, 756.72 and 756.73 added to covered table. Deleted statement added to ICD9 diagnosis code 239.8.

4/29/2010: Policy statement clarified that benefits will not be provided for over-the-counter nutritional supplements or enteral nutrition.

3/26/2012: further policy clarification about nutritionals

SOURCE(S)

Hayes Medical Technology Directory

Blue Cross Blue Shield Association policy #1.02.01

CODE REFERENCE

This is not intended to be a comprehensive list of codes. Some codes may be variable, and coverage will be based on the clinical indication for the service.

Covered Codes

*Some covered procedure codes have multiple descriptions. Coverage will only be made for covered codes when used for services outlined within the policy statement section.

Code Number	Description
CPT-4
97802	Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes (added 8-26-2003)
97803	Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient; each 15 minutes (added 3-23-2005)
97804	Medical nutrition therapy; group (2 or more individual(s), each 30 minutes (added 3-23-2005)
99341, 99342, 99343, 99344, 99345	Home visit for the evaluation and management of a new patient, code range (added 8-26-2003) (description revised 3-23-2005)
99347, 99348, 99349, 99350	Home visit for the evaluation and management of an established patient, code range (added 8-26-2003) (description revised 3-23-2005)
99601	Home infusion/specialty drug administration, per visit (up to 2 hours) (added 8-26-2003)
99602	Home infusion/specialty drug administration, per visit, each additional hour (List separately in addition to primary procedure) (Use 99602 in conjunction with code 99601) (added 8-26-2003)
ICD-9 Procedure
99.15	Parenteral infusion of concentrated nutritional substances (added 8-26-2003)
ICD-9 Diagnosis
141.0, 141.1, 141.2, 141.3, 141.4, 141.5, 141.6, 141.8, 141.9	Malignant neoplasm of base of tongue code range, (added 8-26-2003)
150.0, 150.1, 150.2, 150.3, 150.4, 150.5, 150.8, 150.9	Malignant neoplasm of cervical esophagus code range (added 8-26-2003)
151.0, 151.1, 151.2, 151.3, 151.4, 151.6, 151.8, 151.9	Malignant neoplasm of stomach code range (added 8-26-2003)
195.0	Malignant neoplasm of head, face, and neck (added 8-26-2003)
197.8	Secondary malignant neoplasm of other digestive organs and spleen (added 8-26-2003)
198.89	Secondary malignant neoplasm of other specified sites (added 8-26-2003)
209.63	Benign carcinoid tumor of the stomach (new 10-1-2008)
210.0, 210.1, 210.2, 210.3, 210.4, 210.5, 210.6, 210.7, 210.8, 210.9	Benign neoplasm of lip, oral cavity, and pharynx code range (added 8-26-2003)
211.0	Benign neoplasm of esophagus (added 8-26-2003)
211.1	Benign neoplasm of stomach (added 8-26-2003)
230.0, 230.1, 230.2	Carcinoma in situ of digestive organs code range (added 8-26-2003)
232.4	Carcinoma in situ of scalp and skin of neck (added 8-26-2003)
234.8	Carcinoma in situ of other specified sites (added 8-26-2003)
235.0, 235.1, 235.2, 235.5	Neoplasm of uncertain behavior of the digestive system code range (added 8-26-2003)
238.8	Neoplasm of uncertain behavior of other specified sites (added 8-26-2003)
239.0	Neoplasm of unspecified nature of digestive system (added 8-26-2003)
239.8	Neoplasm of unspecified nature of other specified sites (added 8-26-2003)(Deleted 10-1-2009)
239.81	Neoplasm of unspecified nature, retina and choroid (new 10-1-2009)
239.89	Neoplasm of unspecified nature of other specified sites (new 10-1-2009)
261	Nutritional marasmus (added 8-26-2003)
530.3	Stricture and stenosis of esophagus (AMA description added 8-26-2003)
537.89	Other specified disorder of stomach and duodenum (stricture of the stomach) (AMA description added 8-26-2003)
555.9	Regional enteritis of unspecified site (Crohn's disease ) (AMA description added 8-26-2003)
560.9	Unspecified intestinal obstruction (AMA description added 8-26-2003)
564.89	Other functional disorders of intestine (AMA description added 8-26-2003)
577.0	Acute pancreatitis (AMA description added 8-26-2003)
579.3	Other and unspecified postsurgical nonabsorption (AMA description added 8-26-2003)
579.9	Unspecified intestinal malabsorption (AMA description added 8-26-2003)
643.00	Mild hyperemesis gravidarum, unspecified as to episode of care (AMA description added 8-26-2003)
643.01	Mild hyperemesis gravidarum, delivered (AMA description added 8-26-2003)
643.03	Mild hyperemesis gravidarum, antepartum (AMA description added 8-26-2003)
750.3	Congenital tracheoesophageal fistula, esophageal atresia and stenosis (AMA description added 8-26-2003)
751.2	Congenital atresia and stenosis of large intestine, rectum, and anal canal (AMA description added 8-26-2003)
756.72	Omphalocele (new 10-1-2009)
756.73	Gastroschisis (new 10-1-2009)
756.79	Other congenital anomalies of abdominal wall (AMA description added 8-26-2003)
783.21	Loss of weight (added 8-26-2003)
787.20, 787.21, 787.22, 787.23, 787.24, 787.29	Dysphagia code range (new 10-1-2007)
787.91	Diarrhea (AMA description added 8-26-2003)
997.4	Digestive system complication (AMA description added 8-26-2003)
HCPCS
B4102	Enteral formula for adults, used to replace fluids and electrolytes (e.g., clear liquids), 500 ml = 1 unit (effective 1-1-2005) (added 3-23-2005)
B4103	Enteral formula, for pediatrics, used to replace fluids and electrolytes (e.g., clear liquids), 500 ml = 1 unit (effective 1-1-2005) (added 3-23-2005)
B4104	Additive for enteral formula (e.g., fiber) (effective 1-1-2005) (added 3-23-2005)
B4150	Enteral formula nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit, (description revised 3-23-2005)
B4151	Enteral formula category I; natural intact protein/protein isolates administered through an enteral feeding tube, 100 calories = 1 unit, (description revised and deletion date of 12-31-2004 added 3-23-2005)
B4152, B4153, B4154, B4155	Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals. May include fiber, administered through an enteral feeding tube, 100 calories = 1 unit (description revised 3-23-2005)
B4156	Enteral Formulae, category VI: standardized nutrients, administered through an enteral feeding tube, 100 calories = 1 unit (description revised and deletion date of 12-31-2004 added 3-23-2005)
B4157	Enteral formula, nutritionally complete, for special metabolic needs for inherited disease of metabolism, includes proteins, fates, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit (effective 1-1-2005) (added 3-23-2005)
B4158, B4159, B4160, B4161, B4162	Enteral formula, for pediatrics code range (effective 1-1-2005) (added 3-23-2005)
B4164, B4168, B4172, B4176, B4178, B4180, B4184, B4185, B4186, B4189, B4193, B4197, B4199	Parenteral nutrition solution (added 3-23-2005) (B4184 and B4186 cancelled 12-31-2005) (B4185 New 1-1-2006)
B4216	Parenteral nutrition; additives (vitamins, trace elements, heparin, electrolytes) - home mix, per day (added 3-23-2005)
B5000, B5100, B5200	Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes code range (added 3-23-2005)
G0108	Diabetes outpatient self-management training services, individual, per 30 minutes (added 8-26-2003)
G0109	Diabetes self-management training services, group session (2 or more), per 30 minutes (added 8-26-2003)
All S-codes below include administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem. (added 8-26-2003)
S5517	Home infusion therapy, all supplies necessary for restoration of catheter patency or declotting (added 8-26-2003)
S5518	Home infusion therapy, all supplies necessary for catheter repair (added 8-26-2003)
S5520	Home infusion therapy, all supplies (including catheter) necessary for a peripherally inserted central venous catheter (picc) line insertion (added 5-28-2002) (description revised 8-26-2003)
S5522	Home infusion therapy, insertion of peripherally inserted central venous catheter (picc), nursing services only (no supplies or catheter included) (added 5-28-2002) (description revised 8-26-2003)
All S-codes below include administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment for home enteral feeding, including tubing, swabs, gauze, alcohol wipes, betadine, etc. Enteral formula and nursing visits are coded separately. (added 8-26-2003)
S9340	Home therapy; enteral nutrition; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem (added 5-28-2002)
S9341	Home therapy; enteral nutrition via gravity; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem (added 5-28-2002)
S9342	Home therapy; enteral nutrition via pump; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem (added 5-28-2002)
S9343	Home therapy; enteral nutrition via bolus; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem (added 5-28-2002)
All S-codes below include administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (includes standard TPN formula - lipids, specialty amino acid formulas). Drugs and nursing visits coded separately. (added 8-26-2003)
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) (added 5-28-2002)
S9365	Home infusion therapy, total parenteral nutrition (TPN); one 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 (added 5-28-2002)
S9366	Home infusion therapy, total parenteral nutrition (TPN); more than one liter but no more than two 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 (added 5-28-2002)
S9367	Home infusion therapy, total parenteral nutrition (TPN); more than two liters but no more than three 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 (added 5-28-2002)
S9368	Home infusion therapy, total parenteral nutrition (TPN); more than three 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 (added 5-28-2002)

Non-Covered Codes

*This is not an all inclusive list of non-covered procedure codes.

Code Number	Description
CPT-4

ICD-9 Procedure

ICD-9 Diagnosis

HCPCS
B4149	Enteral formula, manufactured blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit (effective 1-1-2005) (added 3-23-2005) (Description revised 3-9-2006)

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