Article Detail - JD DME

Original Effective Date: 06/01/2004
Revision Effective Date: 11/01/2013

The DMERC Medical Review staff recently conducted a review of total parenteral nutrition (TPN) claims in order to determine the most common mistakes made in the submission of these claims. The following reminders are based on the reviewers' findings.

1. In order to qualify for Medicare coverage, the beneficiary's condition must fall under one of the covered situations described in the Parenteral Nutrition local medical review policy (LMRP) and the beneficiary must need TPN therapy for a minimum of three months. For example, a malnourished beneficiary who is only going to receive TPN for 2-3 weeks prior to surgery does not qualify for coverage.

2. A beneficiary does not qualify under LMRP Situation A (recent massive small bowel resection leaving < 5 feet of small bowel beyond the ligament of Treitz) unless the TPN therapy begins within three months of the date of surgery. If TPN therapy is initiated more than three months following surgery, the beneficiary must qualify under one of the other covered situations in order for Medicare to approve payment.

3. When submitting the initial claim for beneficiaries who meet Situation B TPN coverage criteria (severe short bowel syndrome), the supporting medical records should include intake and output records.

4. A beneficiary with a mechanical small bowel obstruction does not qualify under Situation D unless the obstruction is complete and surgery is not an option. In order for a beneficiary with a partial obstruction to qualify for TPN coverage, records must document a failed enteral nutrition tube trial.

5. Payment will not be approved under Situation E (severe fat malabsorption) unless the medical records include a qualifying 72-hour fecal fat test.

6. If the fecal fat test shows moderate fat malabsorption or the diagnosis of malabsorption is confirmed by a method other than a 72-hour fecal fat test (Sudan stain, d-xylose test, etc.), a failed tube trial is required before TPN coverage will be approved.

7. Medical records submitted to support that a beneficiary qualifies for TPN coverage due to a severe gastrointestinal mobility disturbance (Situation F) must include diagnostic test results that confirm the gastric to right colon transit time is greater than 6 hours.

8. TPN is not covered for gastric to right colon transit times between 3-6 hours unless there is documented evidence of a failed tube trial.

9. There is no Medicare benefit category under which to cover TPN that does not meet the criteria in one of the situations described in the medical policy, or that meet the criteria in the list of noncovered uses of TPN. Bill TPN claims that are not covered under the Prosthetic benefit category coverage with the modifier GY. For example, TPN being administered to treat a temporary condition is not covered and would be billed with modifier GY. An Advance Beneficiary Notice (ABN) is not applicable in this example. An ABN is not applicable for items that are denied because they are statutorily excluded from coverage or that do not meet the definition of any Medicare benefit category.

For additional assistance with TPN claims, refer to the TPN resources posted on the DMERC Medical Review page of the CIGNA Medicare Web site (http://www.cignamedicare.com/dmerc/mr/index.html).