Clinicians, are you ordering parenteral nutrition for your patients?

Parenteral nutrition is the administration of nutritional components intravenously when the patient has an inoperative or malfunctioning digestive tract. Parenteral nutrition is eligible for coverage under the Prosthetic Device benefit (Social Security Act §1861(s)(8)) if the digestive tract is deemed to be permanently inoperative.

Coverage of parenteral nutrition does not require a determination that there is no possibility that the patient’s condition may improve sometime in the future. If the medical record, including the judgment of the treating practitioner, indicates the condition is of long and indefinite duration, the test of permanence is considered met. 

When nutritional support other than the oral route is necessary, enteral nutrition (EN) is usually initially preferable to parenteral nutrition for the following reasons: 

• In a fluid restricted beneficiary, EN permits delivery of all necessary nutrients in a more concentrated volume than parenteral nutrition;
• EN allows for safer home delivery of nutrients; and,
• EN lowers the risk of Central Line-Associated Bloodstream Infections (CLABSI).

For parenteral nutrition to be considered reasonable and necessary, the treating practitioner must document that enteral nutrition has been considered and ruled out, tried and been found ineffective, or that EN exacerbates gastrointestinal tract dysfunction. 

The beneficiary must have:

• A condition involving the small intestine and/or its exocrine glands which significantly impairs the absorption of nutrients; or,
• 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 treating practitioner is required to evaluate the beneficiary within 30 days prior to initiation of parenteral nutrition. 

If the treating practitioner does not see the beneficiary within this timeframe, they must document the reason why and describe what other monitoring methods were used to evaluate the beneficiary's parenteral nutrition needs. There must be documentation in the medical record supporting the clinical diagnosis.

A valid standard written order (SWO) must be in the DME supplier’s possession before they can submit claims to the Medicare program. 

The SWO must contain the following elements:

• Beneficiary's name or Medicare Beneficiary Identifier (MBI)
• Order date
• General description of the item
  • The description can be either a general description (e.g., parenteral nutrition pump), a HCPCS code, a HCPCS code narrative, or a brand name/model number
  • For equipment - In addition to the description of the base item, the SWO may include all concurrently ordered options, accessories, or additional features that are separately billed or require an upgraded code (list each separately)
• Quantity to be dispensed, if applicable
• Treating practitioner name or
• NPI treating practitioner's signature

Adhering to Medicare coverage guidelines support both your patients and the program by ensuring that medical documentation justifies the need for parenteral nutrition. Your role in providing accurate and complete documentation helps Medicare process claims appropriately and ensures your patients receive the medically necessary equipment you have prescribed.

The LCD and Policy Article for parenteral nutrition are located on the DME MAC websites.

DME MAC Jurisdiction Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items for beneficiaries who live in:

Jurisdiction A   CT, DE, MA, ME, MD, NH, NJ, NY, PA, RI, VT, District of Columbia
Jurisdiction B   IL, IN, KY, MI, MN, OH, WI
Jurisdiction C   AL, AR, CO, FL, GA, LA, MS, NM, NC, OK, SC, TN, TX, VA, WV, Puerto Rico, U.S. Virgin Islands
Jurisdiction D   AK, AZ, CA, HI, ID, IA, KS, MO, MT, NE, NV, ND, OR, SD, UT, WA, WY, American Samoa, Guam, Northern Mariana Islands