Parenteral Nutrition

Affected Providers

Physicians, non-physician practitioners, and suppliers who bill for parenteral nutrition.

HCPCS & CPT Codes

Local Coverage Determination (LCD): Parenteral Nutrition (L38953) and Article: Parenteral Nutrition (A58836) have the current HCPCS and CPT codes.

Background

According to the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data, the improper payment rate for parenteral nutrition is 33%, with a projected improper payment amount of $81.9 million.

We cover parenteral nutrition under the prosthetic device benefit. You must meet reasonable and necessary requirements. You must also meet the provisions in LCD L38953. We outline other policy requirements in Article A58836.

When oral feeding can’t sustain a patient because of chronic illness or trauma, they must rely on either enteral or parenteral nutritional therapy, depending on the nature of their medical condition.

Denial Reasons

Insufficient documentation accounted for 69.4% of improper payments for parenteral nutrition during the 2024 reporting period, while medical necessity (9.5%), no documentation (1.3%), incorrect coding (0.1%), and other errors (19.7%) also caused improper payments. “Other” errors include duplicate payment, non-covered or unallowable service, or ineligible Medicare patient errors.

Preventing Denials

To prevent denials, a treating practitioner must meet these conditions:

• Write an order or prescription, provide enough medical documentation to meet the prosthetic device benefit requirements, and show that parenteral nutrition therapy is medically necessary.
• Upon request, provide information describing the medical necessity for parenteral nutrition.
• Document that enteral nutrition was considered and ruled out, that it was tried and found ineffective, or that it exacerbates gastrointestinal tract dysfunction.
• Your patient must have:
  • A condition involving the small intestine, its exocrine glands, or both, that significantly impairs absorbing nutrients or have a disease of the stomach, intestine, or both, that’s a motility disorder and impairs the ability of nutrients to be transported through and absorbed by the gastrointestinal system.
  • A permanent impairment. To satisfy the test of permanence, documentation must show that, in your judgment, the impairment will be of long and indefinite duration. Article A58836 has more information about the test of permanence.

We cover infusion pumps (HCPCS codes B9004 and B9006) for parenteral nutrition. We cover only 1 pump (stationary or portable). We deny more pumps as not reasonable and necessary. We pay based on the reasonable charge for the simplest model that meets the patient’s medical needs, as supported in their medical record.

We routinely cover parenteral therapy nutrient solutions. Refills must occur no sooner than 30 calendar days before the expected end of the current supply. We pay for nutrients based on the reasonable charge for solution components unless the patient’s medical record, including a signed statement from the attending practitioner, shows the patient is unable to mix the solution safely or effectively because of their physical or mental state, and the patient doesn’t have a family member or other person who can do it. We pay based on the reasonable charge for more expensive premixed solutions only under these circumstances.

We consider total caloric daily intake (parenteral, enteral, and oral) of 20–35 cal/kg/day enough to get or keep proper body weight. Document in the patient’s medical record the medical necessity for caloric intake outside this range and make this information available to the Medicare Administrative Contractor (MAC) on request.

Document the medical necessity of:

• Protein orders outside the range of 0.8–2.0 gm/kg/day
• Dextrose concentration less than 10%
• Lipid use per month more than the product-specific, FDA-approved dosing recommendations

Justify medical necessity for a patient who needs special parenteral formulas (HCPCS codes B5000 – B5200). We deny a special parenteral nutrition formula if the medical record doesn’t show why the item is reasonable and necessary.

Suppliers must calculate the units of service for each parenteral product billed to Medicare based on the treating practitioner’s order.

Refill Requirements

For DMEPOS items and supplies provided on a recurring basis, base your billing on prospective, not retrospective use.

Documentation Requirements

To justify payment, you must meet specific requirements when ordering DMEPOS.

Example of Improper Payments Due to Insufficient Documentation for Parenteral Nutrition

A supplier bills the claim for HCPCS code B4185 (Parenteral nutrition solution, not otherwise specified, 10 grams lipids) and submits the following documentation per the review contractor’s request:

• Standard written order with correct HCPCS coding
• Treating practitioner’s medical record that doesn’t prove the patient meets the test of permanence
• Proof of delivery

What Documentation Was Missing?

The patient’s medical documentation doesn’t include documentation to reflect that, in the treating practitioner’s judgment, the impairment will be of long and indefinite duration.

What Happens Next?

The review contractor completes the claim as an insufficient documentation error, and the MAC recoups payment.

Recommendation

To prevent claim denials and improper payments, the certifying physician must collect and submit proper documentation, including meeting the test of permanence criteria, in the treating practitioner’s medical record for DMEPOS.

For specific policy requirements, see Article A58836.