TPN Medicare Guidelines

To qualify for TPN benefit, the patient will require TPN for long and indefinite duration due to one of the below:

  • Condition involving the small intestine and/or its exocrine glands significantly impairing nutrient absorption
  • Disease of the stomach and/or intestine which is a motility disorder and impairs the ability of nutrients to be transported through and absorbed by the gastrointestinal system

Provider documentation:

  • Permanence with TPN in need of long and indefinite duration
    • Why issue is not resolved, requiring long-term/permanent therapy, i.e., why obstruction is not operated on?
    • Documentation must state anticipated length of need
  • Reasonable Need
    • GI system not functional or not functioning enough to maintain health
      • Inoperable & why
      • H&P to support diagnosis need for TPN
      • Progress notes
      • Radiology and other diagnostic reports
      • OR reports
      • Lab results
    • Why Tube feeding is contraindicated
      • Rational for gut rest/not be used
Chartwell reviews all eligible Medicare patients for infusion qualification based on the Noridian LCD found at: External Infusion Pumps LCD and PA ( Noridian has the most current and up to date information. Please refer to the Noridian site for clarification of any content on this site.

Some therapies will have fill and total dose limitations with each qualifying diagnosis. Some therapies will require an electronic external infusion pump, while others will prohibit use of an electronic pump based on the LCD. Medicare covers home infusion under their external infusion pump coverage within the Durable Medical Equipment benefit.

For qualification, provider documentation requires diagnostic testing to support diagnosis for all therapies requiring Medicare qualification. Additionally:
  • The patient must be eligible for a defined Medicare benefit category.
  • Therapy must be reasonable and necessary for the diagnosis and supported in medical documentation.
  • The case must meet all other applicable Medicare statutory and regulatory requirements.