Policy Statement
Our health plan reimburses solutions and medications administered in an inpatient hospital setting based on coding guidelines, revenue codes, CPT codes, HCPCS codes, ICD-10-CM codes, NDC numbers, and documentation provided.
In the inpatient hospital setting, solutions and medications administered, for all routes of administration, are eligible for reimbursement when supported by a treating physician’s signed written or standing order.
- All administered solutions must be recorded in the patient's MAR, eMAR, or anesthesia record to be eligible for reimbursement.
- When an additive and/or nutrient which is not a component of a premixed solution is billed separately, there must be a physician’s signed written order documented in the patient’s medical records to be eligible for separate reimbursement.
- If the physician orders separate administration of one of the components of TPN or solutions, it will be separately reimbursed when documented in the patient’s MAR, eMAR, or anesthesia records.
Additional documentation that must be included in the patient’s record includes, but is not limited to, the name of the drug, date administered, route of administration, actual dose administered to the patient, concentration, and total amount labeled on the container.
In addition, our health plan requires an NDC number, NDC units and units of measurement to be included on the claim in order to determine the standard reimbursement rates and if reimbursement is available.
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., 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., FreAmine HBC®).
- Specialty amino acids with concentrations of 15% and above when medically necessary for fluid restricted members (e.g., Aminosyn® 15%).
- Products serving non-nutritional purposes (e.g., heparin, insulin, Pepcid®, Sandostatin®).
Multiple charges for the same product must be supported by documentation to be eligible for separate reimbursement.
- Documenting a drip rate check, change, or new unit scanned/administered is not sufficient to justify reimbursement for a new unit if it conflicts with the documented drip rate.
The following charges are not separately reimbursable including, but not limited to:
- Unbundling additives and/or nutrients (e.g., carbohydrates, amino acids, electrolytes, trace elements, heparin, vitamins, diluents and medications) in premixed solutions are not eligible for separate reimbursement.
- Diluents which are required to prepare a drug for administration will not be separately reimbursed.
- Hospital-compounded solutions must be billed as a single item when administered in a single bag or syringe for all routes of administration. Individual components are not eligible for separate or individual reimbursement.
- 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.
References
Cross References
- Med 108 – Discarded Drugs and Biologicals
- Adm 129 – Correct Coding Guidelines
