Reimbursement of Intravenous (IV) Solutions, Premixed IV Medications, Epidural, Intra-arterial and Intrathecal Solutions and Total Parenteral Nutrition (TPN) for Facilities

Policy No: 109
Originally Created: 07/01/2016
Section: Facility
Last Reviewed: 12/01/2023
Last Revised: 12/01/2023
Approved: 12/14/2023
Effective: 01/01/2024

The policy applies to inpatient hospital facilities.

Epidural Medications – Medications administered into the epidural space

Intra-arterial Medications – Medications injected into an artery

Intradialytic Parenteral Nutrition (IDPN) - Refers to the infusion of TPN through an existing dialysis access catheter or site to patients with protein calorie malnutrition during hemodialysis.

Intraperitoneal Parenteral Nutrition (IPPN) or Intraperitoneal Amino Acid (IPAA) Supplementation - TPN is provided using a peritoneal dialysate solution with amino acids, instead of or in addition to glucose.

TPN Product categories - There are two (2) basic TPN product categories:

• Commercially premixed multi-chamber TPN bags
• Hospital-compounded, individualized TPN admixtures.

Intrathecal Medications – Medications administered into the subarachnoid space.

Intravenous (IV) Solutions and IV Medications - IV Solutions and medications are solutions administered directly into the venous circulation via a syringe or intravenous catheter (tube).

The Medication Administration Record (MAR or eMAR for electronic version) – The report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional.

Premixed Solutions - A premixed solution contains amino acids, dextrose, electrolytes, and trace elements in a ready-to-be-infused form. Formulations of standing TPN orders for CVC or PICC line administration are very similar to those of commercially premixed TPN. Premixed TPN solutions may require manual addition of electrolytes, trace elements, vitamins and/or drugs before administration to the patient.

Total Parenteral Nutrition (TPN) – The provision of nutritional requirement intravenously via a central venous catheter (CVC) or peripherally-inserted central catheter (PICC) line to correct/prevent specific nutrient deficiencies and to prevent adverse effects of malnutrition when the patient’s gastrointestinal tract either cannot absorb or cannot tolerate adequate food orally or via the tube-feeding route.

For premature or sick neonates, an IV line is often placed in a vein in the infant’s foot, scalp, hand or umbilical vein. Sometimes a PICC line is used for long-term IV nutrition.

Premixed solutions and TPN nutrients or additives include, but are not limited to, the following:

In the inpatient hospital setting, IV solutions, IV medications, intrathecal medications and TPN are eligible for reimbursement when supported by a treating physician's signed written or standing order.

• A reimbursement decision includes but is not limited to reimbursement of multiple intravenous (IV) bags for the same product, when only an IV drip rate change or drip rate check has occurred. Charges for bag changes that conflict with the drip rate for the drug administered, will be considered as a drip rate change. Documentation indicating a new bag scanned and/or administered will not be sufficient to indicate a new bag, if in conflict with the drip rate for the drug administered.

Intravenous (IV) Solutions, Premixed IV Medications, Epidural, Intra-arterial and Intrathecal Solutions and Total Parenteral Nutrition must be recorded in the patient's MAR, eMAR, or anesthesia record to be eligible for reimbursement. Unbundling additives and/or nutrients (e.g., carbohydrates, amino acids, electrolytes, trace elements, heparin, vitamins, diluents and medications) in premixed IV solutions, premixed medications and premixed TPN is not eligible for separate reimbursement.

When an additive and/or nutrient which is not a component of a premixed IV solution, premixed medication or premixed TPN is separately billed, there must be a physician’s signed written order documented in the patient’s medical records to be eligible for separate reimbursement.

Hospital-compounded, individualized TPN admixtures, epidural, intrathecal, intra-arterial or other IV solutions must be billed as a single item when administered in a single bag or syringe. Components and ingredients of compounded, individualized TPN admixtures and other compounded epidural, intrathecal, intra-arterial or other IV solutions are not eligible for separate or individual reimbursement.

If the physician orders separate administration of one of the components of TPN or IV solutions, it will be separately reimbursed when documented in the patient’s MAR, eMAR, or anesthesia records. Diluents which are required to prepare a drug for administration will not be separately reimbursed.

Non-compounded TPN components that may be eligible for separate reimbursement include, but are not limited to, the following:

• Specialty amino acids for renal failure (e.g., Aminess®, Aminosyn-RF®, NephrAmine®, RenAmin®) for IDPN or IPAA.
• Specialty amino acids for hepatic failure (e.g., HepatAmine®)
• Specialty amino acids for high stress conditions (e.g., Aminosyn-HBC®, BranchAmin®, FreAmine HBC®)
• Specialty amino acids with concentrations of 15% and above when medically necessary for fluid restricted members (e.g., Aminosyn® 15%, Novamine® 15%, Clinisol® 15%).
• Specialty amino acids for premature or sick neonates (including low birth weight) and young children (TrophAmine®)
• Standard premix amino acids (e.g., Clinimix®, FreAmine® III)
• Lipids (e.g., Intralipid®, Liposyn®)
• Added trace elements not from a standard multi-trace element solution (e.g., chromium, copper, iodine, manganese, selenium, zinc)
• Added vitamins not from a standard multivitamin solution (e.g., folic acid, vitamin C, vitamin K)

• Products serving non-nutritional purposes (e.g., heparin, insulin, iron dextran, Pepcid®, Sandostatin®, Zofran®)

Parenteral nutrition infusion pump (portable or stationary), parenteral nutrition tubing, IV pole, IV tubing, Viaflex® bags and administration kits are not separately reimbursable. They are included in the room and board charge.

Gargasz, Anne, PharmD, BCPS. Neonatal and Pediatric Parenteral Nutrition. AACN Advanced Critical Care Volume 23, Number 4, pp.451-464

Centers for Medicare & Medicaid Services (CMS), Claims Processing Manual, Chapter 3 – Inpatient Hospital Billing

Centers for Medicare & Medicaid Services (CMS), National Correct Coding Initiative (NCCI) Policy Manual. Chapter 11, Section B. Therapeutic or Diagnostic Infusions/Injections and Immunizations. (Note: In the absence of inpatient guidelines, outpatient guidance is followed)

Centers for Medicare & Medicaid Services (CMS), National Coverage Policy. Coverage Guidance-Coverage Indications, Limitations, and/or Medical Necessity. CMS Pub. 100-3 (National Coverage Determinations Manual), Chapter 1, Section 180.2

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