Medicare Home Parenteral Nutrition Guidelines

Medicare Guidelines

Total parenteral nutrition is the feeding of nutritional products to a person intravenously which bypasses the usual process of eating and digestion. Medicare insured patients needing this type of care post hospitalization must meet the following criteria:

  1. Massive Small Bowel Resection – The patient must have undergone recent (within the past 3 months) massive small bowel resection leaving less than or equal to 5 feet of small bowel beyond the ligament of Treitz.
    1. Operative Report
      1. Date of surgery
      2. Length of remaining small bowel documented
    2. Hospital Discharge Summary
    3. X-Ray Report
    4. Progress Note Supporting Patient Condition
    5. Length of Need Confirmed
      1. Estimated length of need greater than 90 days documented in physician progress note

Important Notes:

Surgery must have occurred within 3 months prior to the initiation of Parenteral Nutrition.

Documentation to support a total daily intake of 20-35kcal/kg may be required.

  1. Short Bowel Syndrome – The patient has less than five feet of small bowel remaining and surgery was performed more than 3 months ago.
    1. Operative Report or Other Objective Test
      1. Length of remaining small bowel documented
    2. Hospital Discharge Summary
    3. Intake/Output Records
      1. Oral/enteral intake is 2.5-3.0 L/Day
      2. GI losses are greater than 50% of oral/enteral intake
      3. Urine output is less than 1 L/Day
    4. Progress Notes Supporting Patient Condition(including labs confirming abnormal electrolytes)
    5. Length of Need Confirmed
      1. Estimated length of need greater than 90 days documented in physician progress note

Important Notes:

Documentation to support a total daily intake of 20-35kcal/kg may be required.

  1. Severe Malabsorption – Patient is significantly malnourished and has documented severe fat malabsorption-72 hour fecal fat test is required.
    1. 10% Weight Loss Over 3 Months or less
      1. Weights and dates must be clearly documented in the record
    2. Serum Albumin 3.4 or Less
    3. Fat Malabsorption confirmed by 72 Hour Fecal Fat Test
      1. Patient consumes diet with at least 50grams of fat/day
      2. Fecal fat exceeds 50% of oral/enteral intake
    4. Progress Notes Supporting Patient Condition
    5. Length of Need Confirmed
      1. Estimated length of need greater than 90 days documented in physician progress note

Important Notes:

Documentation of weight history-recorded weight and date during the 3 months prior to start of parenteral nutrition.

Albumin is used as a diagnosis tool-within 1 week prior to start of parenteral nutrition.

Documentation to support a total daily calorie intake of 20-35kcal/kg may be required.

  1. Complete Small Bowel Obstruction – Patient has a complete mechanical small bowl obstruction where surgery is not an option and tube feeding distal to the obstruction is not possible.
    1. Documented Complete Mechanical Small Bowel Obstruction
      1. Documentation including the underlying cause of obstruction, confirmation by CT, SBFT or other diagnostic test
    2. Confirmation Surgery is Not an Option
      1. Documentation must provide detail on why patient is not a surgical candidate
    3. Confirmed NPO Status
      1. Sips for pleasure or comfort may be considered acceptable
    4. Hospital Discharge Summary
    5. Progress Notes Supporting Patient Condition
    6. Length of Need Confirmed
      1. Estimated length of need greater than 90 days documented in physician progress note

Important Notes:

Post-Operative ileus is not a qualifying diagnosis for Complete Small Bowel Obstruction.

Documentation to support a total daily calorie intake of 20-35kcal/kg may be required.

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