Policy No: 109
Originally Created: 07/01/2016
Last Reviewed: 05/01/2019
Last Revised: 05/01/2019
The policy applies to inpatient hospital facilities.
The Medication Administration Record (MAR or eMAR for electronic version)
The report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional.
Intravenous (IV) Solutions and IV Medications
IV Solutions and medications are solutions administered directly into the venous circulation via a syringe or intravenous catheter (tube).
Total Parenteral Nutrition (TPN)
The provision of nutritional requirement intravenously via a central venous catheter (CVC) or peripherally-inserted central catheter (PICC) line to correct/prevent specific nutrient deficiencies and to prevent adverse effects of malnutrition when the patient's gastrointestinal tract either cannot absorb or cannot tolerate adequate food orally or via the tube-feeding route.
For premature or sick neonates, an IV line is often placed in a vein in the infant's foot, scalp, hand or umbilical vein. Sometimes a PICC line is used for long-term IV feedings.
Intradialytic Parenteral Nutrition (IDPN)
Refers to the infusion of TPN through an existing dialysis access catheter or site to patients with protein calorie malnutrition during hemodialysis for End-Stage Renal Disease (ESRD).
Intraperitoneal Parenteral Nutrition (IPPN) or Intraperitoneal Amino Acid (IPAA) Supplementation
TPN is provided by using a peritoneal dialysate solution with amino acids, instead of or in addition to glucose.
TPN Product categories - There are two (2) basic TPN product categories:
- Commercially premixed multichamber TPN bags
- Hospital-compounded, individualized TPN admixtures.
A premixed solution contains amino acids, dextrose, electrolytes and trace elements in a ready-to-be-infused form. Formulations of standing TPN orders for CVC or PICC line administration are very similar to those of commercially premixed TPN. Premixed TPN solutions may require manual addition of electrolytes, trace elements, vitamins and/or drugs before administration to the patient.
TPN nutrients or additives include, but are not limited to, the following:
Nutrients or Additives
- Amino Acids 8.5%, 10%, 15%
- Ascorbic Acid
- Calcium Chloride
- Calcium Gluconate
- Dextrose 5%, 10%, 30%, 50%, 70%
- Electrolyte Concentration
- Fat Emulsions (lipids) 10%, 20%, 30%
- Folic Acid
- Iron Dextran
- Magnesium Chloride
- Magnesium Sulfate
- Multi-trace Elements (e.g., MTE4, MTE5, MTE7)
- Multivitamin Injection
- Potassium Acetate
- Potassium Chloride
- Potassium Phosphate
- Sodium Acetate
- Sodium Chloride
- Sodium Phosphate
- Sterile Water for Injection
- Vitamin B
- Vitamin D
- Vitamin K
- Zinc Chloride
In the inpatient hospital setting, IV solutions, IV medications and TPN are eligible for reimbursement when supported by a treating physician's signed written order or signed standing IV solution, IV medication or TPN order documented in the patient's MAR or eMAR.
TPN nutrients, additives, IV solutions and medications must be recorded in the patient's MAR or eMAR to be eligible for reimbursement. TPN nutrients, additives, IV solutions, and medications not documented in the MAR or eMAR are not reimbursable. Unbundling additives and/or nutrients (carbohydrates, amino acids, electrolytes, trace elements, heparin, vitamins, diluents and medications) in premixed IV solutions, premixed medications and premixed TPN is not eligible for separate reimbursement.
When an additive and/or nutrient which is not a component of a premixed IV solution, premixed medication or premixed TPN is separately billed, there must be a physician's signed written order documented in the patient's medical records to be eligible for separate reimbursement.
Hospital-compounded, individualized TPN admixtures and other hospital compounded IV solutions must be billed as a single TPN or IV solution when administered as a single bag of TPN or IV solution. Components of compounded, individualized TPN admixtures and compounded IV solutions are not eligible for reimbursement.
If the physician orders separate administration of one of the components of TPN or IV solutions, it will be separately reimbursed when documented in the patient's MAR or eMAR. Diluents which are required to prepare a drug for administration will not be separately reimbursed.
Non-compounded TPN components that may be eligible for separate reimbursement include, but are not limited to, the following:
- Specialty amino acids for renal failure (e.g., Aminess®, Aminosyn-RF®, NephrAmine®, RenAmin®) for IDPN or IPAA.
- Specialty amino acids for hepatic failure (e.g., HepatAmine®)
- Specialty amino acids for high stress conditions (e.g., Aminosyn-HBC®, BranchAmin®, FreAmine HBC®)
- Specialty amino acids with concentrations of 15% and above when medically necessary for fluid restricted members (e.g., Aminosyn® 15%, Novamine® 15%, Clinisol® 15%).
- Specialty amino acids for premature or sick neonates (including low birth weight) and young children (TrophAmine®)
- Standard premix amino acids (e.g., Clinimix, FreAmine® III)
- Lipids (e.g., Intralipid®, Liposyn®)
- Added trace elements not from a standard multi-trace element solution (e.g., chromium, copper, iodine, manganese, selenium, zinc)
- Added vitamins not from a standard multivitamin solution (e.g., folic acid, vitamin C, vitamin K)
- Products serving non-nutritional purposes (e.g., heparin, insulin, iron dextran, Pepcid, Sandostatin, Zofran)
Parenteral nutrition infusion pump (portable or stationary), IV pole and administration kits are not separately reimbursable. They are included in the room and board charge.
Gargasz, Anne, PharmD, BCPS. "Neonatal and Pediatric Parenteral Nutrition." AACN Advanced Critical Care Volume 23, Number 4, pp.451-464
CMS Medicare Claims Processing Manual, Chapter 3 - Inpatient Hospital Billing. 10.4 - Payment of Nonphysician Services for Inpatients
CMS National Correct Coding Initiative (NCCI) Policy Manual. Chapter 11, Section B. Therapeutic or Diagnostic Infusions/Injections and Immunizations.
(Note: In the absence of inpatient guidelines, outpatient guidance is followed)
CMS National Coverage Policy. Coverage Guidance - Coverage Indications, Limitations, and/or Medical Necessity. CMS Pub. 100-3 (National Coverage Determinations Manual), Chapter 1, Section 180.2
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