Parenteral Nutrition - Correct Coding and Billing
Joint DME MAC Article
This Correct Coding and Billing publication is effective for claims with dates of service on or after November 12, 2020.
Parenteral nutrition is covered under the Prosthetic Device benefit (Social Security Act § 1861(s)(8)). In order for a beneficiary's nutrition to be eligible for reimbursement, the reasonable and necessary (R&N) requirements set out in the National Coverage Determinations (NCD) Manual (CMS Pub. 100-03), Chapter 1, Section 180.2, must be met. In addition, there are specific regulatory, payment and coding requirements, discussed below, that also must be met.
If the coverage requirements for parenteral nutrition are met, medically necessary nutrients, administration supplies and equipment are covered.
Suppliers should monitor the beneficiary's medical condition to confirm that the coverage criteria for parenteral nutrition continue to be met.
Parenteral nutrition provided to a beneficiary in a Part A covered stay must be billed by the Skilled Nursing care Facility (SNF) to the A/B MAC. No payment from Part B is available when parenteral nutrition services are furnished to a beneficiary in a stay covered by Part A. However, if the stay is not covered by Part A, parenteral nutrition may be eligible for coverage under Part B and may be billed to the DME MAC, by either the SNF or an outside supplier.
When parenteral nutrition is administered in an outpatient facility, the pump and IV pole, used for its administration, are not separately payable. The pump and pole are not considered as rentals to a single beneficiary, but rather as items of equipment used for multiple beneficiaries.
GENERAL DOCUMENTATION REQUIREMENTS
In order to justify payment for DMEPOS items, suppliers must meet the following requirements:
- Standard Written Order (SWO)
- Medical Record Information (including continued need/use if applicable)
- Correct Coding
- Proof of Delivery
No more than one month's supply of parenteral nutrients, equipment or supplies is allowed for one month's prospective billing. Claims submitted retroactively, however, may include multiple months.
The treating practitioner is expected to see the beneficiary within 30 days prior to the initial certification or required recertification (but not revised certifications). If the treating practitioner does not see the beneficiary within this timeframe, he/she must document the reason why and describe what other monitoring methods were used to evaluate the beneficiary's parenteral nutrition needs.
A total caloric daily intake (parenteral, enteral and oral) of 20-35 cal/kg/day is considered sufficient to achieve, or maintain, appropriate body weight. The treating practitioner must document in the medical record the medical necessity for a caloric intake outside this range in an individual beneficiary. This information must be available on request.
The treating practitioner must document the medical necessity for protein orders outside of the range of 0.8-1.5 gm/kg/day, dextrose concentration less than 10%, or lipid use greater than 1500 grams (150 units of service of code B4185 or B4187) per month.
The medical necessity for special parenteral formulas (B5000, B5100, B5200) must be justified in each beneficiary. If a special parenteral nutrition formula is provided and if the medical record does not document why that item is reasonable and necessary, it will be denied as not reasonable and necessary.
EQUIPMENT AND SUPPLIES
Infusion pumps (B9004 or B9006) are covered for beneficiaries in whom parenteral nutrition is covered. Only one pump (stationary or portable) will be reimbursed at any one time.
If the coverage requirements for parenteral nutrition are met, one supply kit (B4220 or B4222) and one administration kit will be reimbursed for each day that parenteral nutrition is administered.
DME INFORMATION FORM (DIF)
A DME Information Form (DIF) which has been completed, signed, and dated by the supplier, must be kept on file by the supplier and made available upon request.
The DIF for Enteral Nutrition is CMS Form 10126. The initial claim must include an electronic copy of the DIF.
A new Initial DIF is required when parenteral nutrition services are resumed after an interruption of need or billing of parenteral nutrition in two prior consecutive months.
A revised DIF for enteral nutrients is required when:
- Change in HCPCS code for the current nutrient provided.
- Change (increase or decrease) in the calories prescribed for any HCPCS codes other than B4189, B4193, B4197, B4199, B5000, B5100, B5200.
- Change in the number of days per week of administration.
- Change in route of administration from central line to hemodialysis access line to peritoneal catheter.
- When the length of need previously entered on the DIF has expired and the treating practitioner is extending the length of need for the item(s).
When homemix parenteral nutrition solutions are used, the component carbohydrates (B4164, B4180), amino acids (B4168, B4172, B4176, B4178), additives (B4216) and lipids (B4185 or B4187) are all separately billable. When premix parenteral nutrition solutions are used (B4189, B4193, B4197, B4199, B5000, B5100, B5200) there must be no separate billing for the carbohydrates, amino acids or additives (vitamins, trace elements, heparin, electrolytes). However, lipids (B4185 or B4187) are separately billable with premix solutions.
For lipids, one unit of service, of code B4185 or B4187, is billed for each 10 grams of lipids provided; 500 ml of 10% lipids contains 50 grams of lipids (5 units of service); 500 ml of 20% lipids contains 100 grams (10 units of service); 500 ml of 30% lipids contains 150 grams (15 units of service).
When an IV pole (E0776) is used in conjunction with parenteral nutrition, the BA modifier should be added to the code. Code E0776 is the only code with which the BA modifier may be used.
For codes B4189, B4193, B4197, B4199, one unit of service represents one day's supply of protein and carbohydrate regardless of the fluid volume and/or the number of bags. For example, if 60 grams of protein are administered per day, in two bags of a premix solution, each containing 30 grams of amino acids, correct coding is one (1) unit of B4193; not two units of B4189.
For codes B5000, B5100, B5200, one unit of service is one gram of amino acid.
Parenteral nutrition solutions containing less than 10 grams of protein per day are coded using the miscellaneous code B9999.
Suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items.
Group 1 Codes:
|B4164||PARENTERAL NUTRITION SOLUTION: CARBOHYDRATES (DEXTROSE), 50% OR LESS (500 ML = 1 UNIT) - HOME MIX|
|B4168||PARENTERAL NUTRITION SOLUTION; AMINO ACID, 3.5%, (500 ML = 1 UNIT) - HOME MIX|
|B4172||PARENTERAL NUTRITION SOLUTION; AMINO ACID, 5.5% THROUGH 7%, (500 ML = 1 UNIT) - HOME MIX|
|B4176||PARENTERAL NUTRITION SOLUTION; AMINO ACID, 7% THROUGH 8.5%, (500 ML = 1 UNIT) - HOME MIX|
|B4178||PARENTERAL NUTRITION SOLUTION: AMINO ACID, GREATER THAN 8.5% (500 ML = 1 UNIT) - HOME MIX|
|B4180||PARENTERAL NUTRITION SOLUTION; CARBOHYDRATES (DEXTROSE), GREATER THAN 50% (500 ML = 1 UNIT) - HOME MIX|
|B4185||PARENTERAL NUTRITION SOLUTION, NOT OTHERWISE SPECIFIED, 10 GRAMS LIPIDS|
|B4187||OMEGAVEN, 10 GRAMS LIPIDS|
|B4189||PARENTERAL NUTRITION SOLUTION; COMPOUNDED AMINO ACID AND CARBOHYDRATES WITH ELECTROLYTES, TRACE ELEMENTS, AND VITAMINS, INCLUDING PREPARATION, ANY STRENGTH, 10 TO 51 GRAMS OF PROTEIN - PREMIX|
|B4193||PARENTERAL NUTRITION SOLUTION; COMPOUNDED AMINO ACID AND CARBOHYDRATES WITH ELECTROLYTES, TRACE ELEMENTS, AND VITAMINS, INCLUDING PREPARATION, ANY STRENGTH, 52 TO 73 GRAMS OF PROTEIN - PREMIX|
|B4197||PARENTERAL NUTRITION SOLUTION; COMPOUNDED AMINO ACID AND CARBOHYDRATES WITH ELECTROLYTES, TRACE ELEMENTS AND VITAMINS, INCLUDING PREPARATION, ANY STRENGTH, 74 TO 100 GRAMS OF PROTEIN - PREMIX|
|B4199||PARENTERAL NUTRITION SOLUTION; COMPOUNDED AMINO ACID AND CARBOHYDRATES WITH ELECTROLYTES, TRACE ELEMENTS AND VITAMINS, INCLUDING PREPARATION, ANY STRENGTH, OVER 100 GRAMS OF PROTEIN - PREMIX|
|B4216||PARENTERAL NUTRITION; ADDITIVES (VITAMINS, TRACE ELEMENTS, HEPARIN, ELECTROLYTES), HOME MIX, PER DAY|
|B4220||PARENTERAL NUTRITION SUPPLY KIT; PREMIX, PER DAY|
|B4222||PARENTERAL NUTRITION SUPPLY KIT; HOME MIX, PER DAY|
|B4224||PARENTERAL NUTRITION ADMINISTRATION KIT, PER DAY|
|B5000||PARENTERAL NUTRITION SOLUTION COMPOUNDED AMINO ACID AND CARBOHYDRATES WITH ELECTROLYTES, TRACE ELEMENTS, AND VITAMINS, INCLUDING PREPARATION, ANY STRENGTH, RENAL-AMINOSYN-RF, NEPHRAMINE, RENAMINE-PREMIX|
|B5100||PARENTERAL NUTRITION SOLUTION COMPOUNDED AMINO ACID AND CARBOHYDRATES WITH ELECTROLYTES, TRACE ELEMENTS, AND VITAMINS, INCLUDING PREPARATION, ANY STRENGTH, HEPATIC, HEPATAMINE-PREMIX|
|B5200||PARENTERAL NUTRITION SOLUTION COMPOUNDED AMINO ACID AND CARBOHYDRATES WITH ELECTROLYTES, TRACE ELEMENTS, AND VITAMINS, INCLUDING PREPARATION, ANY STRENGTH, STRESS-BRANCH CHAIN AMINO ACIDS-FREAMINE-HBC-PREMIX|
|B9004||PARENTERAL NUTRITION INFUSION PUMP, PORTABLE|
|B9006||PARENTERAL NUTRITION INFUSION PUMP, STATIONARY|
|B9999||NOC FOR PARENTERAL SUPPLIES|