TMPPM 2007 >27.3 Benefits and Limitations

27.3 Benefits and Limitations

In-home TPN/hyperalimentation is a benefit for eligible clients who require long-term support because of extensive bowel resection and/or severe advanced bowel disease in which the bowel cannot support nutrition. Texas Health Steps (THSteps)-Comprehensive Care Program (CCP) clients birth through 20 years of age with diagnoses other than those mentioned above require prior authorization through CCP. Covered services must be reasonable, medically necessary, appropriate, and prescribed by a physician. TPN/hyperalimentation is not available through the traditional Medicaid program when oral intake will maintain adequate nutrition.

TPN/hyperalimentation must be prior authorized. The request for prior authorization must be submitted by the physician prescribing the treatment and must include the following documentation to support the medical necessity of the TPN/hyperalimentation:

•A completed Medicaid Certificate of Medical Necessity for In-Home Total Parenteral Nutrition form that is signed and dated by the physician.

•A clear copy of the most recent laboratory results (to include potassium, calcium, albumin, and liver function studies).

•A clear copy of the total parenteral nutrition (TPN) formula/prescription, including amino acids and lipids, signed and dated by the physician. The administration of intravenous fluids and electrolytes cannot be billed as in-home TPN/hyperalimentation.

Requests must include all pertinent medical records as required by HHSC or TMHP to indicate the medical necessity of the long-term TPN/hyperalimentation. Prior authorization may be given for up to one year, subject to renewal every year with the submission of a supplemental report documenting continued medical necessity for the treatment.

Refer to: "Medical Necessity for In-Home Total Parenteral Hyperalimentation (TPN)" on page B-56.

Covered services include, but are not necessarily limited to, the following:

•TPN/hyperalimentation solutions and additives as ordered by the client's physician.

•Supplies and equipment, including refrigeration (if necessary), that are required for the administration of prescribed solutions and additives.

•Education of the client and/or caregivers regarding the in-home administration of TPN/hyperalimentation before the initial administration begins. Education must include the use and maintenance of required supplies and equipment.

•Visits by a registered nurse appropriately trained in the administration of TPN/hyperalimentation. The nurse must visit the client at least once per month to monitor the client's status and to provide ongoing education to the client and/or family members/support people about the administration of TPN/hyperalimentation.

•Enteral supplies, nutritional products, and equipment, if medically necessary, in conjunction with TPN/hyperalimentation.

Hospitals administering TPN/hyperalimentation in the hospital outpatient department should refer to "Outpatient Total Parenteral Nutrition/Hyperalimentation" for the policies and billing instructions.

TPN/hyperalimentation is payable only once per day, per client. No more than a one-week supply of solutions and additives will be reimbursed if the solutions and additives are shipped and not used because of the client's loss of eligibility, change in treatment, or inpatient hospitalization. Any days that the client is an inpatient in a hospital or other medical facility or institution must be excluded from the daily billing. TPN may be reimbursed in the inpatient hospital setting using the reimbursement methodology of that facility. Payment for partial months will be prorated based on actual days of administration.

Lipids (9-B4185) will be denied if billed on the same date of service as any other TPN procedure code (1-S9364, 1-S9365, 1-S9366, 1-S9367, or 1-S9368).

All supporting documentation must be included with the request for authorization. Send requests and documentation to the following address:

Texas Medicaid & Healthcare Partnership
Special Medical Prior Authorization
12357-B Riata Trace Parkway, Suite 150
Austin, TX 78727
Fax: 1-512-514-4213