amerihealth
Advanced Search

Total Parenteral Nutrition (TPN) / Intradialytic Parenteral Nutrition (IDPN)
MA08.008h

Policy

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This policy uses coverage criteria developed solely based on applicable Medicare statutes, regulations, NCDs, LCDs, CMS manuals and other applicable Medicare coverage documents.​

MEDICALLY NECESSARY

TOTAL PARENTERAL NUTRITION
Initial Therapy for Malnutrition

Total parenteral nutrition (TPN), for initial​ therapy, is considered medically necessary and, therefore, covered when ALL of the following are met:
  • Documentation of ONE of the following:
    • A condition involving the small intestine and/or its exocrine glands that significantly impairs the absorption of nutrients
    • A disease of the stomach and/or intestine that is a motility disorder and impairs the ability of nutrients to be transported through and absorbed by the gastrointestinal (GI) system
  • Documentation of ONE of the following:
    • Enteral nutrition (EN) has been considered and ruled out
    • EN has been tried and found ineffective 
    • EN exacerbates GI tract dysfunction 
  • Documentation of ONE of the following: 
    • Individual was evaluated by the ordering professional provider within 30 days prior to the initiation of TPN
    • If the individual was not seen within this timeframe, the reason why AND what other monitoring methods were used to evaluate the need for TPN
  • Documentation of a permanent impairment* 
  • Documentation supports the clinical diagnosis resulting in the need for TPN including ALL of the following:
    • All the diagnoses related to the TPN therapy
    • Duration of the condition(s)
    • Estimated duration of therapy (i.e., in months, years, or for life)
    • Clinical course (worsening or improvement)
    • Prognosis
    • Nature and extent of functional limitations (i.e., what precludes the individual from absorbing nutrients from the alimentary tract and the ability to maintain weight and strength)
    • Other therapeutic interventions and results 
    • Other medical conditions that may affect the individual’s nutritional needs 
    • Past experience with related items 
    • The individual’s nutritional requirements to certify the TPN therapy provided​
*Coverage of TPN requires that an individual must have a permanent impairment. However, this does not require a determination that there is no possibility that the individual’s condition may improve sometime in the future. If the medical record, including the judgment of the treating professional provider, indicates that the impairment will be of long and indefinite duration, the test of permanence is considered met.​

Continuation Therapy for Malnutrition

Continuation of TPN is considered medically necessary and, therefore, covered when there is documentation in the individual’s medical records that there is continued medical need for TPN.

INTRADIALYTIC PARENTERAL NUTRITION
Intradialytic parenteral nutrition (IDPN) is considered medically necessary and, therefore, covered when it is infused as an alternative to a regularly scheduled regimen of TPN in individuals who meet the medical necessity criteria for TPN, not in addition to a regularly scheduled infusion of TPN. 

For individuals with a functional GI tract, IDPN is not covered under the medical benefit (Part B); however, IDPN, in members with a functional GI tract, may be considered for coverage under the Pharmacy Benefit (Part D), if such a benefit exists. ​
​​​
SPECIAL FORMULATIONS OF PARENTERAL NUTRITION ​​
Special nutrient formulas are produced to meet the unique nutrient needs for specific disease conditions. The individual’s medical record must adequately document the specific condition and the necessity for the special nutrient. ​

ASSOCIATED SERVICES

When an infusion therapy service is covered, all associated services (e.g., solutions, additives, equipment and/or supplies, nursing) are considered covered and eligible for reimbursement. ​

When an infusion therapy service is noncovered, all associated services (e.g., solutions, equipment and/or supplies, nursing) are considered noncovered and ineligible for reimbursement. 

REQUIRED DOCUMENTATION

For individuals who meet the criteria for TPN, a total daily caloric intake of 20 to 35 kcal/kg/day is considered sufficient to achieve or maintain appropriate body weight. A total daily protein intake of 0.8 to 2.0 g/kg/day, dextrose concentration 10 percent or greater, and lipid use in alignment with the product-specific US Food and Drug Administration (FDA)-approved dosing recommendations is considered sufficient. The ordering professional provider must document the medical necessity for orders outside of these ranges for these nutrients.

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation. 

STANDARD WRITTEN ORDER REQUIREMENTS​ 
​Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY REQUIREMENTS 
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.​

CONSUMABLE SUPPLIES (WHEN APPLICABLE)
For items and supplies provided on a recurring basis, billing must be based on prospective, not retrospective use. For products that are supplied as refills to the original order, suppliers must contact the beneficiary, and document an affirmative response, prior to dispensing the refill and not automatically ship on a pre-determined basis, even if authorized by the beneficiary. This shall be done to ensure that the refilled item remains reasonable and necessary, existing supplies are expected to end, and to confirm any changes or modifications to the order. Contact with the beneficiary or designee regarding refills must take place no sooner than 30 calendar days prior to the expected end of the current supply. For delivery of refills, the supplier must deliver the product no sooner than 10 calendar days prior to the expected end of the current supply. This is regardless of which delivery method is utilized. Regardless of utilization, a supplier must not dispense more than a 1-month quantity at a time.

If required documentation is not available on file to support a claim at the time of an audit or record request, the durable medical equipment (DME) supplier may be required to reimburse the Company for overpayments.​

Guidelines

MEDICARE DETERMINATION

This policy is consistent with Medicare’s coverage determination. The Company’s payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, total parenteral nutrition (TPN), intradialytic parenteral nutrition (IDPN), and intraperitoneal nutrition (IPN)​ are covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.​

For individuals with a functional gastrointestinal tract, IDPN is not covered under the medical benefit (Part B); however, IDPN, in members with a functional gastrointestinal tract, may be considered for coverage under the Pharmacy Benefit (Part D), if such a benefit exists.

MACRONUTRIENTS

 

The following tables are examples of ranges for macronutrients for adult and pediatric individuals. The macronutrients for an individual should be determined based upon their clinical situation.

Macronutrients for Adult Individuals

Clinical State

Daily Protein Intake (g/kg)

Daily Energy Intake (kcal/kg)

Dextrose Intake (mg/kg/min)

Daily Fat Emulsions (g/kg)

Daily Fluid Intake (ml/kg)

Stable

0.8-1.5

20-35

4-5

1

30-40

Critically ill

1.2-2.5

12-25 in the early ICU stay

<3-4

<1

Minimal to provide adequate macronutrients

Burns

1.5-2.0

20-30

4-5

1

30-40

Open abdomen

Additional 15-30 g/L exudate

20-30

4-5

1

30-40

Acute kidney injury

0.8-2.0

20-30

4-5

1

30-40

Continuous renal replacement therapy

Additional 0.2 g/kg/d not to exceed 2.5 g/kg/d

25-35

4-5

1

30-40

Chronic kidney disease (CKD) stages 3-5 without diabetes

0.55-0.60

25-35

4-5

1

30-40

CKD stages 3-5 with diabetes

0.6-0.8

25-35

4-5

1

30-40

CKD 5D on maintenance hemodialysis or peritoneal dialysis

1.2-1.5

25-35

4-5

1

30-40

Hepatic failure

1.2-2.0 based on “dry” weight and tolerance

20-30

4-5

1

30-40

Obese

2.0-2.5 based on ideal body weight (IBW)

22-25 based on IBW

4-5

1

30-40

 

 

Macronutrients for Pediatric Individuals 

Infants (<1yr)

Initiation

Advance by

Goals

Preterm

Term

Preterm

Term

Preterm

Term

Daily protein intake (g/kg) (use higher end of range for critically ill)

1.5

1.5

N/A

N/A

2.5-3.5

3.0

Dextrose intake (mg/kg/min)

4-8

2.5-5.0

Increase gradually over 2-3 days

Increase gradually over 2-3 days

8-10 (max 12)

5-10 (max 12)

Daily fat emulsions (g/kg)

0.5-1.0

0.5-1.0

0.5-1.0

0.5-1.0

3-4

2.5-4.0

Children (1 to 10 yrs) Stable (Critically ill-when different)

Daily protein intake (g/kg)

1

N/A

1-2 (use higher end of range for critically ill)

Dextrose intake (mg/kg/min)

3-6

1-2

8-10

Daily fat emulsions (g/kg)

1-2

0.5-1.0

2-3 (2-4 with monitoring of triglycerides)

Adolescents (11 to <18 yrs) Stable (Critically ill-when different)

Daily protein intake (g/kg)

1

N/A

1-2 (use higher end of range for critically ill)

Dextrose intake (mg/kg/min)

2.5-3.0

1-2

5-6

Daily fat emulsions (g/kg)

1

1

1-2 (2-4 with monitoring of triglycerides)​


If the individual is at a high risk of developing refeeding issues, the TPN may need to be initiated at 50 percent of the target caloric and protein intake and be titrated up over the course of the first few days to weeks. A total fluid intake of 30 to 40 mL fluid/kg/d (account for extra output from drains or fistulas and additional input from other sources such as IV drugs) will be needed to maintain hydration status. If appropriate, electrolytes, minerals, and micronutrients may need to be added but should be individualized based on the individual’s specific needs and comorbidities.

Description

Malnutrition is defined in the American Society for Parenteral and Enteral Nutrition (ASPEN​) guidelines as: “an acute, subacute, or chronic state of nutrition in which a combination of varying degrees of overnutrition or undernutrition, with or without inflammatory activity, has led to a change in body composition and diminished function.” The malnutrition can have any number of causes including, but not limited to, anorexia, intestinal disease/failure, acute/chronic pancreatitis, burns, trauma, and sepsis. The malnutrition can be the result of inadequate intake of nutrients, increased requirements for nutrients, altered/impaired absorption of nutrients, altered/impaired transportation of the nutrients through the gastrointestinal (GI) tract, or altered/impaired utilization of the nutrients by the body. 

TOTAL PARENTERAL NUTRITION (TPN)

Malnutrition exists when there is a deficiency of nutrients such as protein, energy, and micronutrients that cause adverse effects on an individual's body function, body composition, or on the individual's clinical outcome or vulnerability to additional adverse effects or events. Strategies to improve or maintain adequate nutrition include the administration of oral nutritional supplements (ONS), enteral nutrition (EN) where the nutrition is infused directly into the GI tract through a tube or catheter, or parenteral nutrition (PN). PN is the provision of nutritional requirements intravenously. PN is administered through a central intravenous line access or a peripherally inserted central catheter (PICC), often in the home. An infusion pump regulates the flow of the solution on either a continuous (24-hour) or intermittent schedule. PN consists of the optimal levels of glucose, amino acids, electrolytes, vitamins, minerals, and fats; the concentration of each component is calculated for the individual's specific metabolic need. The benefit of PN is that it is a life-sustaining source of nutrition for individuals who are unable to meet their nutritional needs through an oral or enteral route, usually due to impaired GI tract function. The use of PN may be temporary, such as an individual who experiences hyperemesis gravidarum (HG), or it may be permanent, such as an individual with intestinal failure. PN can be infused during hemodialysis or peritoneal dialysis, in certain circumstances. When nutritional support other than the oral route is necessary, EN is usually initially preferable to PN for the following reasons: 

  • In a fluid-restricted individual, EN permits delivery of all necessary nutrients in a more concentrated volume than PN 
  • EN allows for safer home delivery of nutrients 
  • EN lowers the risk of central line–associated bloodstream infections (CLABSI) 
  • Even small amounts of EN can help support and maintain intestinal function 
INTRADIALYTIC PARENTERAL NUTRITION (IDPN)

Protein-energy wasting (PEW) is the term used for the loss of body protein mass and fuel reserves seen in chronic kidney disease (CKD). PEW is associated with increased morbidity and mortality among individuals with CKD. PEW can be diagnosed if certain characteristics are present in an individual. These include, but are not limited to, low serum albumin, reduced body mass (low/reduced body/fat mass or weight loss associated with the reduced intake of protein and/or energy), and reduced muscle mass (muscle wasting). According to the literature, the prevalence of PEW in individuals on chronic hemodialysis (HD) ranges between 20 and 70 percent. The prevalence increases with the individual’s age and number of years on HD. It is estimated that the annual mortality rate is between 20 and 30 percent for individuals undergoing HD who are malnourished. The life expectancy for these individuals is 3 to 11 years shorter than individuals not on chronic HD. 

Many factors associated with renal failure can contribute to PEW in individuals receiving chronic HD. These can include decreased oral intake/anorexia, dietary restrictions, loss of nutrients (including amino acids) during HD, loss of water-soluble vitamins during HD, loss of blood during HD, loss of electrolytes during HD, uremic toxicity, physical inactivity, metabolic acidosis, impaired lipolysis, GI issues (impaired absorption of nutrients, gastroparesis), endocrine issues (increased leptin levels, peripheral insulin resistance, hyperparathyroidism), protein catabolism, and chronic microinflammation. Feeding through the GI tract is the preferred route for nutritional intake, but if that is not possible, then PN is an alternative. 

Intradialytic PN is the administration of PN while the individual is undergoing HD. The PN is infused three times a week through the venous line. Some benefits of IDPN include reduced protein catabolism, improved nutritional parameters (e.g., albumin, prealbumin), some parameters that improve quality of life for the individual, decreased PEW-related complications including mortality, and IDPN may reduce hospitalization rates. Some drawbacks to infusing IDPN during HD include that clinical studies have been unable to demonstrate an improvement in the individuals’ overall nutritional status, an improvement in most quality-of-life parameters, or an overall increase in the 2-year survival of individuals receiving IDPN along with ONS as well as the possibility of adverse effects occurring due to the rapid infusion of glucose and lipids during a HD session. It is therefore recommended that individuals on HD with severe PEW receive daily PN if their nutritional needs cannot be supplied by the oral or enteral route.

​OFF-LABEL INDICATIONS

There may be additional indications contained in the Policy section of this document due to evaluation of criteria highlighted in the Company’s off-label policy, and/or review of clinical guidelines issued by leading professional organizations and government entities.​

References

American Gastroenterological Association. American Gastroenterological Association medical position statement: guidelines for the use of enteral nutrition. Gastroenterology. 1995;108:1280-1301.

American Gastroenterological Association. American Gastroenterological Association medical position statement: parenteral nutrition. Gastroenterology. 2001;121(4):966-969.

American Society for Parenteral and Enteral Nutrition (ASPEN). Appropriate dosing for parenteral nutrition: ASPEN recommendations. [ASPEN web site]. 11/17/2020. Available at: https://nutritioncare.org/clinical-resources/parenteral-nutrition/essential-resources/ [via subscription only]. Accessed October 8, 2025.

Burkart JM, Bansal S. Malnutrition and protein intake in patients on peritoneal dialysis. [Up To Date web site]. 08/28/2025. Available at: https://www.uptodate.com/contents/malnutrition-and-protein-intake-in-patients-on-peritoneal-dialysis?search=Nutritional status and protein intake in peritoneal dialysis patients&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 [via subscription only]. Accessed October 8, 2025​.

Brown RO, Compher C, et al. A.S.P.E.N. clinical guidelines: nutrition support in adult acute and chronic renal failure. JPEN J Parenter Enteral Nutr. 2010;34(4):366-377.

Cano NJM, Aparicio M, Brunori G, et al. ESPEN guidelines on parenteral nutrition: adult renal failure. Clin Nutr. 2009;28:401-414.

Cano NJM, Fouque D, Roth H, et al. Intradialytic parenteral nutrition does not improve survival in malnourished hemodialysis patients: a 2-year multicenter, prospective, randomized study. J Am Soc Nephrol. 2007;18(9):2583-2591.

Cederholm T, Jensen GL, Correia MITD, et al. GLIM criteria for the diagnosis of malnutrition - a consensus report from the global clinical nutrition community. J Cachexia Sarcopenia Muscle. 2019;10:201-217.

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 15. Covered medical and other health services. Revised 04/11/2025. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS012673. Accessed October 8, 2025. 

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 8. Outpatient ESRD hospital, independent facility, and physician/supplier claims. 11/22/2024. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912. Accessed October 8, 2025.

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 20. Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). 03/28/2024. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912. Accessed October 8, 2025. 

Centers for Medicare & Medicaid Services (CMS). Medicare Prescription Drug Benefit Manual. Chapter 6. Part D drugs and formulary requirements. 01/15/2016. Available at: https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/pub100_18.pdf. Accessed October 8, 2025.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) 180.2: Enteral and parenteral nutritional therapy – RETIRED. 04/10/2023. Available at: https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=242&ncdver=3&bc=0. Accessed October 8, 2025.

Compher C, Bingham AL, McCall M, et al. Guidelines for the provision of nutrition support therapy in the adult critically ill patient: the American Society for Parenteral and Enteral Nutrition. JPEN J Parenter Enteral Nutr. 2022;46(1):12-41. ​

Durfee SM, Adams SC, Arthur E, et al. A.S.P.E.N. standards for nutrition support: home and alternate site care. Nutr Clin Pract. 2014;29(4):542-555.

Elsevier clinical overview. Nausea and vomiting of pregnancy and hyperemesis gravidarum. [Elsevier web site]. 11/20/2024. Available at: https://www.clinicalkey.com/#!/content/clinical_overview/67-s2.0-693def4b-3a08-4947-bac5-7687fb04d12b. Accessed October 8, 2025.​

Evidence of Coverage.

Fejzo MS, Poursharif B, Korst, et al. Symptoms and pregnancy outcomes associated with extreme weight loss among women with hyperemesis gravidarum. J Women’s Health (Larchmt). 2009;18(12):1981-1987.

Herrell HE. Nausea and vomiting of pregnancy. Am Fam Physician. 2014;89(12):965-970.

Ikizler TA, Burrowes JD, Byham-Gray LD, et al. KDOQI clinical practice guideline for nutrition in CKD: 2020 update. Am J Kidney Dis. 2020;76(3)(suppl 1):S1-S107.

Korzets A, Azoulay O, Ori Y, et al. The use of intradialytic parenteral nutrition in acutely ill haemodialysed patients. J Ren Care. 2008;34(1):14-18.

Kuscu NK, Koyuncu F. Hyperemesis gravidarum: current concepts and management. Postgrad Med J. 2002;78:76-79.

Lapillonne A, Fidler Mis N, Goulet O, et al.; ESPGHAN/ESPEN/ESPR/CSPEN working group on pediatric parenteral nutrition. ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: lipids. Clin Nutr. 2018;37(6 Pt B):2324-2336.

Marsen TA, Beer J, Mann H, et al. Intradialytic parenteral nutrition in maintenance hemodialysis patients suffering from protein-energy wasting. Results of a multicenter, open, prospective, randomized trial. Clin Nutr. 2017;36(1):107-117.

Mehta NM, Compher C; ASPEN Board of Directors. A.S.P.E.N. Clinical Guidelines: nutrition support of the critically ill child. JPEN J Parenter Enteral Nutr. 2009;33(3):260-276.

Mesotten D, Joosten K, van Kempen A, et al.; ESPGHAN/ESPEN/ESPR/CSPEN working group on pediatric parenteral nutrition. ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: carbohydrates. Clin Nutr. 2018;37(6 Pt B):2337-2343.

Mirtallo J, Canada T, Johnson D, et al; Task Force for the Revision of Safe Practices for Parenteral Nutrition. Safe practices for parenteral nutrition. JPEN J Parenter Enteral Nutr. 2004;28(6):S39-S70. ​

National Institute for Health and Care Excellence (NICE). Nutritional support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition. [NICE web site]. 08/04/2017. Available at: https://www.nice.org.uk/guidance/cg32. Accessed October 8, 2025.

National Kidney Foundation. KDOQI Clinical Practice Guideline for Nutrition in Children with CKD: 2008 update. Am J Kidney Dis. 2009;53(3)(Suppl 2):S1-124.

Noridian. Enteral and parenteral nutrition refill requirements. 06/20/2024. Available at:  https://med.noridianmedicare.com/web/jadme/article-detail/-/view/6547796/enteral-and-parenteral-nutrition-refill-requirements. Accessed October 8, 2025.  

Noridian. Local Coverage Article (LCA). A55426: Standard documentation requirements for all claims submitted to DME MACs. Effective date 01/01/2024. Revision date 01/01/2024. Available at:  https://med.noridianmedicare.com/web/jadme/policies/lcd/active. Accessed October 8, 2025.

Noridian. Local Coverage Article (LCA). A58836: Parenteral Nutrition. Effective date 07/02/2023. Revision date 07/02/2024. Available at: https://med.noridianmedicare.com/web/jadme/policies/lcd/active. Accessed October 8, 2025.​ 

Noridian. Local Coverage Determination (LCD). L38953: Parenteral Nutrition. Effective date 01/01/2024. Revision date 01/01/2024. Available at: https://med.noridianmedicare.com/web/jadme/policies/lcd/active. Accessed October 8, 2025.

Sigrist MK, Levin A, Tejani AM. Systematic review of evidence for the use of intradialytic parenteral nutrition in malnourished hemodialysis patients. J Ren Nutr. 2010;20(1):1-7. Epub 2009 Sep 27.

Singer P, Blaser AR, Berger MM, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr. 2019;38(1):48-79.

Smith JA, Fox KA, Clark SM. Nausea and vomiting of pregnancy: treatment and outcome. [Up To Date web site]. 08/28/25. Available at: https://www.uptodate.com/contents/nausea-and-vomiting-of-pregnancy-treatment-and-outcome?search=Nausea and vomiting of pregnancy: treatment and outcome&source=search_result&selectedTitle=1~102&usage_type=default&display_rank=1 [via subscription only]. Accessed October 8, 2025.

van Goudoever JB, Carnielli V, Darmaun D; ESPGHAN/ESPEN/ESPR/CSPEN working group on pediatric parenteral nutrition. ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: amino acids. Clin Nutr. 2018;37(6 Pt B):2315-2323. 

White JV, Guenter P, Jensen G, et al. Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). JPEN J Parenter Enteral Nutr. 2012:36(3):275-283.

Worthington P, Balint J, Bechtold M, et al. When is parenteral nutrition appropriate? JPEN J Parenter Enteral Nutr. 2017;41(3):324-377.​​​​

Coding

CPT Procedure Code Number(s)
N/A
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
N/A
HCPCS Level II Code Number(s)

THE FOLLOWING CODES ARE USED TO REPRESENT HOME INFUSION THERAPY


S9364 Home infusion therapy, total parenteral nutrition (TP N); 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 (do not use with home infusion codes S9365-S9368 using daily volume scales)

S9365 Home infusion therapy, total parenteral nutrition (TP N); 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 (do not use with home infusion codes S9365-S9368 using daily volume scales)

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

S9368 Home infusion therapy, total parenteral nutrition (TPN); 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


THE FOLLOWING CODES ARE USED TO REPRESENT PARENTERAL NUTRITION SOLUTIONS


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 g 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

B4216Parenteral nutrition; additives (vitamins, trace elements, heparin, electrolytes) - home mix, per day


THE FOLLOWING CODES ARE USED TO REPRESENT SPECIALIZED NUTRITION SOLUTIONS


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


THE FOLLOWING CODE IS USED TO REPRESENT PARENTERAL NUTRITION SOLUTIONS CONTAINING LESS THAN 10 GRAMS OF PROTEIN PER DAY


B9999 NOC for parenteral supplies


THE FOLLOWING CODES ARE USED TO REPRESENT PARENTERAL NUTRITION EQUIPMENT AND SUPPLIES


B4220 Parenteral nutrition supply kit; premix, per day

B4222 Parenteral nutrition supply kit; home mix, per day

B4224 Parenteral nutrition administration kit, per day

B9004 Parenteral nutrition infusion pump, portable

B9006 Parenteral nutrition infusion pump, stationary

E0776 IV Pole

Revenue Code Number(s)
N/A


Coding and Billing Requirements

Policy History

Revisions From MA08.008h:
03/16/2026

This version of the policy will become effective 03/16/2026. 


The following criteria have been deleted from this policy:

  • Indications for hyperemesis gravidarum and intraperitoneal parenteral nutrition (IPN)
  • Complete bowel rest ​

The following policy criteria have been revised:

  • Documentation requirements have been revised to be more concise and in accordance with Centers for Medicare & Medicaid Services (CMS) documentation requirements

Revisions From MA08.008g:
01/01/2025This version of the policy will become effective 01/01/2025. 

Documentation requirements have been revised in alignment with Noridian Local Coverage Determination [LCD] 38953 Parenteral Nutrition​ [effective 01/01/2024]).

Revisions From MA08.008f:
01/01/2024
​Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
07/03/2023
This version of the policy will become effective 07/03/2023.

Policy criteria have been revised in alignment with Noridian Local Coverage Determination [LCD] 38953 Parenteral Nutrition​ [effective 01/01/2022]), professional medical society guidelines, and peer-reviewed literature.

The following has been added to the Guidelines section of the policy:
Tables containing examples of macronutrient ranges for adult and pediatric individuals in alignment with Noridian Local Coverage Determination [LCD] 38953 Parenteral Nutrition​ [effective 01/01/2022]), professional medical society guidelines, and peer-reviewed literature.​

Revisions From MA08.008e:
11/22/2021
This version of the policy will become effective 11/22/2021. 

Criteria have been revised in alignment with Centers for Medicare & Medicaid Services (CMS) guidance (National Coverage Determination [NCD] 180.2 Enteral and Parenteral Nutrition Therapy [effective 07/11/1984] and Noridian Local Coverage Determination [LCD] 38953 Parenteral Nutrition​ [effective 09/05/2021]) and professional medical society guidelines.​

The following HCPCS codes were added to this policy:​

  • B4187 omegaven, 10 grams lipids
  • E0776 IV Pole​

Revisions From MA08.008d:
01/01/2020This version of the policy will become effective 01/01/2020. The following HCPCS code B4185 has a revised narrative.

Revisions From MA08.008c:
07/17/2019The policy has been reviewed and reissued to communicate the Company's continuing position on Total Parenteral Nutrition (TPN) / Intradialytic Parenteral Nutrition (IDPN) / Intraperitoneal Nutrition (IPN).
11/21/2018This policy became effective 9/21/2016. It has been reviewed and reissued to communicate the Company’s continuing position on Total Parenteral Nutrition (TPN) / Intradialytic Parenteral Nutrition (IDPN) / Intraperitoneal Parenteral Nutrition (IPN).
06/21/2017This policy has been reissued in accordance with the Company's annual review process.
09/21/2016The policy criteria was expanded regarding Specialized Formulations, to include coverage of solutions such as Proplete. Updates were made to the Coding Table to allow for billing by eligible participating home infusion companies.

Revisions From MA08.008b:
01/29/2016 The intent of this policy remains unchanged, but the policy has been updated to further clarify current benefits.

Revisions From MA08.008a:
01/01/2016 The following HCPCS narratives have been revised in this policy effective 1/1/2016.

B5000
FROM: Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, renal - Amirosyn RF, nephramine, renamine - premix
TO: 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
FROM: Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, hepatic - Freamine HBC, HepatAmine - premix
TO: Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, hepatic, hepatamine-premix

B5200
FROM: Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, stress - branch chain amino acids – premix

TO: 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

Revisions From MA08.008:
01/01/2015This is a new policy.
3/16/2026
3/16/2026
MA08.008
Medical Policy Bulletin
Medicare Advantage
No