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Date Printed: October 17, 2017: 04:25 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

09-A4000-04

Original Effective Date: 10/15/02

Reviewed: 04/23/15

Revised: 10/01/17

Subject: Hyperalimentation

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Hyperalimentation, also known as total parenteral nutrition (TPN), is used for patients with medical conditions that impair gastrointestinal absorption to a degree that can be 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. Hyperalimentation 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 typically used to prevent clotting inside the catheter.

POSITION STATEMENT:

 

Certificate of Medical Necessity

Submit a completed Certificate of Medical Necessity (CMN) along with your request to expedite the medical review process.

1. Click the link Hyperalimentation - Certificate of Medical Necessity (MS Word) to open the form.

2. Complete all fields on the form thoroughly.

3. Print and submit a copy of the form with your request.

Note: Florida Blue regularly updates CMNs. Ensure you are using the most current copy of a CMN before submitting to Florida Blue. For a complete list of available CMNs, visit the Certificates of Medical Necessity page.

Hyperalimentation services and supplies for administration of intravenous home hyperalimentation meet the definition of medical necessity when administered for a diagnosis or condition such as, but not limited to, anatomical or functional loss of enteric absorptive surface sufficient to produce nutritional depletion not otherwise correctable.

Examples of conditions for which hyperalimentation meet the definition of medical necessity include the following:

Hyperalimentation includes the following services and supplies:

Hyperalimentation services and supplies do not meet the definition of medical necessity when used in the following situations, as they are not the standard of practice for the use of hyperalimentation services:

BILLING/CODING INFORMATION:

The following codes may be used to report hyperalimentation services:

HCPCS Coding:

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

S9366

Home infusion therapy, total parenteral nutrition (TPN); more than 1 liter but no more than 2 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

S9367

Home infusion therapy, total parenteral nutrition (TPN); more than 2 liters but no more than 3 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

ICD-10 Diagnoses Codes That Support Medical Necessity:

C15.3 – C15.9

Malignant neoplasm of esophagus

C16.0 – C16.9

Malignant neoplasm of stomach

C78.80, 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

E41

Nutritional marasmus

E43

Unspecified severe protein-calorie malnutrition

E44.0

Moderate protein-calorie malnutrition

E45

Retarded development following protein-calorie malnutrition

E46

Unspecified protein-calorie malnutrition

E64.0

Sequelae of protein-calorie malnutrition

K22.2

Esophageal obstruction

K31.6

Fistula of stomach and duodenum

K31.89

Other diseases of stomach and duodenum

K50.00 – K50.919

Crohn's disease of small intestine without complications

K51.00 – K51.919

Ulcerative colitis

K52.21

Food protein-induced enterocolitis syndrome

K52.22

Food protein-induced enteropathy

K52.29

Other allergic and dietetic gastroenteritis and colitis

K52.831 – K52.839

Colitis

K52.89

Other specified noninfective gastroenteritis and colitis

K55.011 – K55.019

Acute ischemia of small intestine

K63.2

Fistula of intestine

K85.00 – K85.92

Acute pancreatitis

K90.2

Blind loop syndrome, not elsewhere classified

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

K91.81

Other intraoperative complications of digestive system

K91.89

Other postprocedural complications and disorders of digestive system

N32.1

Vesicointestinal fistula

Q39.0 – Q39.9

Congenital malformation of esophagus

Q40.2, Q40.3

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

T28.1xxA, T28.1xxD, T28.1xxS

Burn of esophagus

T28.2xx1A,
T28.2xx1D,
T28.2xx1S

Burn of other parts of alimentary tract

T28.6xxA,
T28.6xxD,
T28.6xxS

Corrosion of esophagus

T28.7xx1A,
T28.7xx1D,
T28.7xx1S

Corrosion of other parts of alimentary tract

T66.xxxA,
T66.xxxD,
T66.xxxS

Radiation sickness, unspecified, initial encounter

REIMBURSEMENT INFORMATION:

Reimbursement for hyperalimentation is limited to three (3) liters per day.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Enteral and Parenteral Nutrition Therapy (180.2), located at cms.gov.

The following Durable Medical Equipment Regional Carrier (DMERC) Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Parenteral Nutrition (L11561) located at cgsmedicare.com.

DEFINITIONS:

Crohn’s disease: ileitis that typically involves the distal portion of the ileum, often spreads to the colon, and is characterized by diarrhea, cramping, and loss of appetite and weight with local abscesses and scarring; also referred to as regional enteritis, regional ileitis.

Malabsorption: faulty absorption of nutrient materials from the alimentary canal; also referred to as malassimilation.

Malnutrition: an acute, subacute, or chronic state of nutrition in which a combination of varying degrees of overnutrition or undernutrition with or without inflammatory activity have led to a change in body composition and diminished function.

Radiation enteritis: inflammation of the intestines and especially of the human ileum resulting from radiation therapy.

Short bowel syndrome: malabsorption from the small intestine that is marked by diarrhea, malnutrition, and steatorrhea and that results from resection of the small intestine.

Steatorrhea: an excess of fat in the stools.

Ulcerative colitis: a nonspecific inflammatory disease of the colon that is of unknown cause and is characterized by diarrhea with discharge of mucus and blood, cramping abdominal pain, and inflammation and edema of the mucous membrane with patches of ulceration.

RELATED GUIDELINES:

OTHER:

Indexing terms:

REFERENCES:

  1. American Gastroenterological Association Medical Position Statement: Parenteral Nutrition, Volume 121, Number 4, October 2001, accessed 07/31/07.
  2. American Medical Association CPT (current edition).
  3. Blue Cross Blue Shield Association Medical Policy 1.02.01 – Total Parenteral Nutrition and Enteral Nutrition in the Home, 04/03 (archived 06/09).
  4. Centers for Medicare & Medicaid Services (CMS), National Coverage Determination (NCD) for Enteral and PARENTERAL NUTRITIONal Therapy (180.2), 07/11/84; accessed at cms.gov 04/03/15.
  5. Centers for Medicare and Medicaid Services; Region C DMERC Local Coverage Determination (LCD): Parenteral Nutrition (L11561), 08/05/11; accessed at cgsmedicare.com 04/03/15.
  6. Merriam Webster Medical Dictionary (online edition accessed 08/22/02).
  7. St. Anthony’s ICD-9-CM Code Book (current edition).

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 04/23/15.

GUIDELINE UPDATE INFORMATION:

10/15/02

Reformatted; diagnosis list expanded; local codes removed.

01/01/04

Annual HCPCS coding update.

07/15/04

Scheduled review; no changes.

03/15/05

Revision consisting of adding S9366 and S9367.

09/15/07

Review, coverage statements maintained, guideline reformatted, references updated.

10/15/10

Revision; related ICD-10 codes added.

10/01/11

4th Quarter coding update: removed ICD-9 997.4; added 997.49.

05/11/14

Revision: Program Exceptions section updated.

06/03/14

Revision: Program Exceptions section updated.

05/15/15

Review; position statements maintained; definition section and references updated.

10/01/15

Revision; ICD9 & ICD10 coding sections updated.

11/01/15

Revision: ICD-9 Codes deleted.

10/01/16

ICD-10 coding update: codes K52.21 – K52.29, K52.831-K52.839, K55.011-K55.019, K85.00-K85.92, & K90.49 added; codes K52.2, K55.0, K85.0, K85.9, & K90.4 deleted.

10/01/17

Quarterly CPT/HCPCS coding update: deleted K91.3.

Date Printed: October 17, 2017: 04:25 PM