Navigating Reimbursement for Home Parenteral Nutrition

Abstract

Reimbursement for home parenteral nutrition (HPN) is important for nutrition support clinicians to understand. This intent of this review is to provide nutrition support clinicians knowledge on navigating through the structured requirements of diagnosis driven billing to receive reimbursement for services related to HPN, provide information on coding, provide practical tips for surviving a Medicare billing audit, and discuss challenges of Medicare guidelines seen in clinical practice.

The use of advanced medical technologies at home: a systematic review of the literature

“…[31]UKQualitative methods;Purposive sampling strategyFace-to-face semi structured interviews; n = 36 (families)Ventilators;Feeding pumps;Dialysis machines; Oxygen therapy; Intravenous drug therapies; Tracheostomies;Suction machinesNeuro-disability;Respiratory disability;Renal disability;Neuro-degenerative disability;Gastrointestinal disability;Cardiac disability;Metabolic disability;Congenital abnormality disability;Haematological disabilityFamilies’ experiences of caring for a technology-dependent child were examined, exploring the multiple rhythms and routines around which the families’ lives were variously structured.Hendrickson, E., Corrigan, M.L., 2013. [106]USAReviewHome parenteral nutrition (HPN)No medical diagnosis mentionedProvide nutrition support clinicians knowledge on navigating through the structured requirements of diagnosis driven billing to receive reimbursement for services related to HPN, provide information on coding, provide practical tips for surviving a Medicare billing audit, and discuss challenges of Medicare guidelines seen in clinical practice.Hewitt-Taylor, J., 2004. [56]UKDescriptive study;Quantitative survey;Initial fact finding;Questionnaire n = 21 (staff caring for children requiring assisted ventilation)Long-term assisted ventilation;Continuous Positive Airway Pressure (CPAP);Bilevel Positive Airway Pressure (BiPAP).No medical diagnosis mentionedA study of the perceived education and training needs of staff who care for children with complex needs, including assisted ventilation, and their families.Hilbers, E.S.M., de Vries, C.G.J.C.A., Geertsma, R.E., 2013.…”

When Is Parenteral Nutrition Appropriate?

“…Recommendation 10C: Unfortunately, insurance coverage figures prominently in decisions regarding HPN. Considerable variation exists in HPN reimbursement practices for commercial payers and federal insurance programs 25 . Although insurers recognize home care as a cost‐effective alternative to a prolonged hospital stay, the costs associated with PN have led many third‐party payers to develop eligibility criteria aimed at confirming medical necessity for HPN.…”

“…Although insurers recognize home care as a cost‐effective alternative to a prolonged hospital stay, the costs associated with PN have led many third‐party payers to develop eligibility criteria aimed at confirming medical necessity for HPN. For example, the Centers for Medicare and Medicaid Services (CMS) have established strict conditions that must be met to qualify for HPN reimbursement 25 . The approval process for HPN frequently requires documentation of the diagnostic and clinical factors that preclude oral intake or EN, which may include evidence of failed EN trials, operative reports, results of laboratory tests, and imaging studies 2 , 4 , 25 , 26 .…”

“…For example, the Centers for Medicare and Medicaid Services (CMS) have established strict conditions that must be met to qualify for HPN reimbursement 25 . The approval process for HPN frequently requires documentation of the diagnostic and clinical factors that preclude oral intake or EN, which may include evidence of failed EN trials, operative reports, results of laboratory tests, and imaging studies 2 , 4 , 25 , 26 . Even after receiving confirmation of coverage, patients sometimes bear responsibility for substantial out‐of‐pocket costs 25 .…”

“…The approval process for HPN frequently requires documentation of the diagnostic and clinical factors that preclude oral intake or EN, which may include evidence of failed EN trials, operative reports, results of laboratory tests, and imaging studies 2 , 4 , 25 , 26 . Even after receiving confirmation of coverage, patients sometimes bear responsibility for substantial out‐of‐pocket costs 25 . More detail regarding CMS HPN eligibility criteria is publicly available through the CMS website, https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=242&ncdver=1&bc=AAAAQAAAAAAA 27…”