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OREGON HEALTH AUTHORITY, DIVISION OF MEDICAL ASSISTANCE PROGRAMS

 

DIVISION 148

HOME ENTERAL/PARENTERAL NUTRITION AND IV SERVICES

410-148-0000

Foreword

(1) The Home Enteral/Parenteral Nutrition and IV Services rules are a user's manual designed to assist providers in preparing health claims for medical assistance program clients. The Home Enteral/Parenteral Nutrition and IV Services provider rules are to be used in conjunction with the General Rules for Oregon Medical Assistance Programs, the Oregon Health Plan administrative rules, the Pharmaceutical Services Administrative Rules, and other relevant provider rules and supplemental information.

(2) The Home Enteral/Parenteral Nutrition and IV Services provider rules include procedure codes with restrictions, and limitations. The Home EPIV code and fee schedule, which is not a part of these rules, is not an exhaustive list of OHP covered service codes. Please consult the Prioritized List of Health Services for the Oregon Health Plan and the DMAP Maximum Allowable Table.

(3) The Division endeavors to furnish medical providers with up-to-date billing, procedural information, and guidelines to keep pace with program changes and governmental requirements.

(4) Providers should always follow the the Division's administrative rules in effect on the date of service.

[Publications: Publications referenced are available from the agency.]

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: HR 26-1990, f. 8-31-90, cert. ef. 9-1-90; HR 3-1995, f. & cer.t ef. 2-1-95; OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0600 OMAP 63-2003, f. 9-5-03, cert. ef. 10-1-03; OMAP 15-2004, f. 3-11-04, cert. ef. 4-1-04

410-148-0020

Home Enteral/Parenteral Nutrition and IV Services

(1) The Division of Medical Assistance Programs (Division) will make payment for medically appropriate goods, supplies and services for home enteral/parenteral nutrition and IV therapy on written order or prescription. (a) The order or prescription must be dated and signed by a licensed prescribing practitioner, legible and specify the service required, the ICD-9-CM diagnosis codes, number of units and length of time needed.

(b) The prescription or written physician order for solutions and medications must be retained on file by the provider of service for the period of time specified in the Division's General Rules.

(c) An annual assessment and a new prescription are required once a year for ongoing services.

(d) Also covered are services for subcutaneous, epidural and intrathecal injections requiring pump or gravity delivery.

(2) All claims for enteral/parenteral nutrition and IV services require a valid ICD-9-CM diagnosis code. It is the provider's responsibility to obtain the actual diagnosis code(s) from the prescribing practitioner. Reimbursement will be made according to covered services on funded lines of the Health Services Commission's Prioritized List of Health Services, and these rules.

(3) The Division requires one initial nursing service visit to assess the home environment and appropriateness of enteral/parenteral nutrition or IV services in the home setting and to establish the client's treatment plan.

(a) This nursing service visit for assessment purposes does not require payment authorization.

(b) The nursing service assessment visit is not required when:

(A) The only service provided is oral nutritional supplementation;

(B) The services are performed in an Ambulatory Infusion Suite of the home infusion therapy provider.

(4) Nursing service visits specific to this Home Enteral/Parenteral and IV services program are provided in the home, or an Ambulatory Infusion Suite of the Home Infusion Therapy Provider (AIS) and will be reimbursed by the Division only when prior authorized, and performed by a person who is licensed by the Oregon State Board of Nursing to practice as a Registered Nurse. All registered nurse delegated or assigned nursing care tasks must comply with the Oregon State Board of Nursing, Nurse Practitioner Act and Administrative Rules regulating the practice of nursing.

(5) Payment for services identified in the Home Enteral/Parenteral Nutrition and IV Services provider rules will be made only when provided in the client's place of residence (i.e., home or nursing facility) or an Ambulatory Infusion Suite (AIS).

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: AFS 56-1989, f. 9-28-89, cert. ef. 10-1-89; HR 26-1990, f. 8-31-90, cert. ef. 9-1-90, Renumbered from 461-016-0290; HR 9-1992, f. & cert. ef. 4-1-92; HR 26-1993, f. & cert. ef. 10-1-93; HR 3-1995, f. & cert. ef. 2-1-95; OMAP 7-1998, f. 2-27-98, cert. ef. 3-1-98; OMAP 29-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0640; OMAP 22-2003, f. 3-26-03, cert. ef. 4-1-03; OMAP 63-2003, f. 9-5-03, cert. ef. 10-1-03; OMAP 15-2004, f. 3-11-04, cert. ef. 4-1-04; OMAP 64-2004, f. 9-10-04, cert. ef. 10-1-04; DMAP 11-2007, f. 6-14-07, cert. ef. 7-1-07

410-148-0040

Requirements for Home Enteral/Parenteral Nutrition and IV Services

(1) Home Enteral/Parenteral Nutrition and IV Services:

(a) Home enteral/parenteral nutrition and IV services must include training and/or education of client or support person on nutritional supplement and /or equipment operation;

(b) When enteral/parenteral nutrition and IV services are initiated in a hospital setting, reimbursement for training is included in the hospital reimbursement and will not be made separately;

(c) Reimbursement for enteral/parenteral and IV services training when done in the home is included in the payment for the nursing visit(s);

(d) Per diem reimbursement includes: administrative service, pharmacy professional and cognitive services, including drug admixture, patient assessment, clinical monitoring, and care coordination, and all necessary infusion related supplies and equipment. Enteral/parenteral formula, drugs and nursing visits are not included in per diem rates and must be billed separately.

(2) Home enteral nutrition:

(a) Home enteral nutrition is considered medically appropriate to maintain body mass and prevent nutritional depletion, which occurs with some illnesses or pathological conditions;

(b) Home enteral therapy may be administered orally or by enteral tube feeding, i.e., nasogastric, jejunostomy or gastrostomy delivery systems.

(3) Home parenteral nutrition:

(a) Is considered medically appropriate for treatment of gastrointestinal dysfunction such as severe short bowel syndrome, chronic radiation enteritis, severe Crohn's disease, or other conditions where adequate nutrition by the oral and enteral routes is not possible:

(b) Initiation of home parenteral nutrition services must include client or support person education on catheter care, infusion technique, solution preparation, sterilization technique, and equipment operation;

(c) Parenteral nutrition is appropriate only when oral or enteral feeding is inadequate or contraindicated.

(4) Home intravenous (IV) services:

(a) Home intravenous (IV) services are covered by the Division for the administration of antibiotics, analgesics, chemotherapy, hydrational fluids or other intravenous medications in a client's residence, (i.e., home or nursing facility) or an Ambulatory Infusion Suite (AIS).

(b) In addition, the provision of all goods and services needed for maintaining venous or arterial access and required monitoring is covered.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: HR 26-1990, f. 8-31-90, cert. ef. 9-1-90; HR 9-1992, f. & cert. ef. 4-1-92; HR 22-1993(Temp), f. & cert. ef. 9-1-93; HR 34-1993(Temp), f. & cert. ef. 12-1-93; HR 11-1994, f. 2-25-94, cert. ef. 2-27-94; HR 3-1995, f. & cert. ef. 2-1-95; OMAP 29-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0660; OMAP 22-2003, f. 3-26-03, cert. ef. 4-1-03; DMAP 11-2007, f. 6-14-07, cert. ef. 7-1-07

410-148-0060

Authorization

(1) The Division of Medical Assistance Programs (Division) requires authorization of payment for the following items or services:

(a) All enteral/parenteral or IV infusion pumps. The provider is required to submit documentation with each request proving that other (non-pump) methods of delivery do not meet the client's medical need;

(b) All nursing service visits, except the assessment nursing visit, associated with home enteral/parenteral nutrition or IV services;

(c) All oral nutritional supplements;

(d) All drugs and goods identified as requiring payment authorization in the Pharmaceutical Services administrative rules (chapter 410, division 121). Contact the Division’s Pharmacy Benefit Manager to determine those items that require prior authorization.

(2) The Division will approve payment for the above home enteral/parenteral nutrition and/or IV services entities when they are considered to be "medically appropriate."

(3) The Division requires authorization of payment for those services that require authorization even though the client has other insurance that may cover the service. Authorization of payment is not required for Medicare covered services.

(4) For services requiring authorization, providers must contact the Division’s Medical Unit for authorization within five working days following initiation of services. Authorization will be given based on medical appropriateness, appropriateness of level of care given, cost and/or effectiveness.

(5) How to obtain payment authorization:

(a) The Division’s Medical Unit is responsible for authorization for services for clients identified as Medically Fragile Children's Unit clients;

(b) Contact the Division’s Pharmacy Benefit Manager, prior authorization help desk to request oral nutrition supplements;

(c) Contact the Division’s Medical Unit to request all other authorization;

(d) Payment authorization does not guarantee reimbursement.

[Publications: Publications referenced are available from the agency.]

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: PWC 818(Temp), f. 10-22-76, ef. 11-1-76; PWC 831, f. 2-18-77, ef. 3-1-77; PWC 869, f. 12-30-77, ef. 1-1-78; AFS 70-1981, f. 9-30-81, ef. 10-1-81; AFS 44-1982, f. 4-30-82 & AFS 52-1982, f. 5-28-82, ef. 5-1-82 for providers located in the geographical areas covered by the branch offices of North Salem, South Salem, Dallas, Woodburn, McMinnville, Lebanon, Albany and Corvallis, ef. 6-30-82 for remaining AFS branch offices; AFS 99-1982, f. 10-25-82, ef. 11-1-82; AFS 12-1984, f. 3-16-84, ef. 4-1-84; AFS 26-1984, f. & ef. 6-19-84; AFS 53-1985, f. 9-20-85, ef. 10-1-85; AFS 52-1986, f. & ef. 7-2-86; AFS 15-1987, f. 3-31-87, ef. 4-1-87; AFS 4-1989, f. 1-31-89, cert. ef. 2-1-89; AFS 56-1989, f. 9-28-89, cert. ef. 10-1-89, Renumbered from 461-016-0090; HR 26-1990, f. 8-31-90, cert. ef. 9-1-90, Renumbered from 461-016-0220; HR 9-1992, f. & cert. ef. 4-1-92; HR 26-1993, f. & cert. ef. 10-1-93; HR 3-1995, f. & cert. ef. 2-1-95; OMAP 7-1998, f. 2-27-98, cert. ef. 3-1-98; OMAP 29-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0680; OMAP 22-2003, f. 3-26-03, cert. ef. 4-1-03; OMAP 63-2003, f. 9-5-03, cert. ef. 10-1-03; DMAP 26-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 38-2011, f. 12-13-11, cert. ef. 1-1-12

410-148-0080

Equipment Rental/Purchase/Repair

(1) The following equipment shall be authorized, if medically appropriate and when cost effective, on a rental basis only:

(a) IV infusion pumps;

(b) Enteral formulae pumps.

(2) The equipment provider is responsible for providing working equipment including replacement if repairs are necessary.

(3) Pump rental payment will not be made beyond the purchase price, but no more than 15 consecutive months when the period of use extends beyond 15 consecutive months:

(a) Consecutive months are defined as "any period of continuous use where no more than a 60-day break occurs";

(b) Division of Medical Assistance Programs (Division) considers that the maximum rental period toward purchase price is -- 15 consecutive months of pump rental. The purchase price has been met at the earlier of the purchase price or 15 consecutive months;

(c) Having met the purchase price as described in this rule, the pump becomes property of the client, and the patient is responsible for all maintenance and repairs.

(A) The Division can still allow for medically necessary repairs on equipment that the patient owns.

(B) The provider may bill the Division for maintenance and servicing of the pump (as long as that maintenance and servicing is not covered under any manufacturer/supplier warranty) when a period of at least six months has elapsed since the final month of pump rental. Payment for the maintenance service will only be made one time during every six-month period.

(C) For a purchased pump, a rental pump may be prior authorized for up to one month during equipment repair for a client requiring medically necessary, continuous service.

(4) All other equipment for home enteral/parenteral nutrition and IV services will be authorized as either purchase or based on length of need and medical appropriateness.

(5) All rental or purchase of equipment, full services warranty, pickup, delivery, set-up, fitting and adjustments are included in the reimbursement. Individual consideration may be given in specific circumstances upon written request to the Division.

(6) Repair of rental equipment is the responsibility of the provider.

(7) The Division will not make payment for rental of pumps that are supplied by any manufacturer at no cost to the provider.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: HR 26-1990, f. 8-31-90, cert. ef. 9-1-90; HR 20-1991, f. & cert. ef. 4-16-91; HR 3-1995, f. & cert. ef. 2-1-95; OMAP 7-1998, f. 2-27-98, cert. ef. 3-1-98; OMAP 29-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0700; OMAP 15-2004, f. 3-11-04, cert. ef. 4-1-04; OMAP 64-2004, f. 9-10-04, cert. ef. 10-1-04

410-148-0095

Client Copayments

Copayments may be required for non-American Indian/Alaska Native clients for certain services. See OAR 410-120-1230 for specific details.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: OMAP 91-2002, f. 12-24-02, cert. ef. 1-1-03

410-148-0100

Reimbursement

(1) Drug ingredients (medications) shall be reimbursed as defined in the Division of Medical Assistance Programs (Division) Pharmaceutical Services Administrative rules (chapter 410, division 121).

(2) The following service/goods will be reimbursed on a fee-for-service basis according to the Division EPIV Fee Schedule found in the Home Enteral/Parenteral Nutrition and IV Services on the Division website:

(a) Enteral formula;

(b) Oral nutritional supplements which are medically appropriate and meet the criteria specified in 410-148-0260(3);

(c) Parenteral nutrition solutions;

(3) Reimbursement for services will be based on the lesser of the amount billed, or the Division maximum allowable rate. When the service is covered by Medicare, reimbursement will be based on the lesser of the amount billed, Medicare’s allowed amount, or the Division maximum allowable rate.

(4) Reimbursement for supplies that require authorization or services/supplies that are listed as Not Otherwise Classified (NOC) or By Report (BR) must be billed to the Division at the providers' acquisition cost, and will be reimbursed at such rate.

(a) For purposes of this rule, Acquisition Cost is defined as the actual dollar amount paid by the provider to purchase the item directly from the manufacturer (or supplier) plus any shipping and/or postage for the item. Submit documentation identifying acquisition cost with your authorization request;

(b) Per diem, as it relates to reimbursement, represents each day that a given patient is provided access to a prescribed therapy. This definition is valid for per diem therapies of up to and including every 72 hours.

(c) Per diem reimbursement includes, but is not limited to:

(A) Professional pharmacy services:

(i) Initial and ongoing assessment/clinical monitoring;

(ii) Coordination with medical professionals, family and other caregivers;

(iii) Sterile procedures, including IV admixtures, clean room upkeep and all biomedical procedures necessary for a safe environment;

(iv) Compounding of medication/medication set-up.

(B) Infusion therapy related supplies:

(i) Durable, reusable or elastomeric disposable infusion pumps;

(ii) All infusion or other administration devices;

(iii) Short peripheral vascular access devices;

(iv) Needles, gauze, sterile tubing, catheters, dressing kits, and other supplies necessary for the safe and effective administration of infusion therapy.

(C) Comprehensive, 24-hour per day, seven days per week delivery and pickup services (includes mileage).

(5) Reimbursement will not be made for the following:

(a) Central catheter insertion or transfusion of blood/blood products in the client's home;

(b) Central catheter insertion in the nursing facility;

(c) Intradialytic parenteral nutrition in the client's home or Nursing Facility;

(d) Oral infant formula that is available through the Women’s, Infant and Children (WIC) program;

(e) Oral nutritional supplements that are in addition to consumption of food items or meals.

(f) Tocolytic pumps for pre-term labor management;

(g) Home enteral/parenteral nutrition or IV services outside of the client's place of residence (i.e. home, nursing facility or AIS).

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: HR 26-1990, f. 8-31-90, cert. ef. 9-1-90; OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0720; OMAP 3-2003, f. 1-31-03, cert. ef. 2-1-03; OMAP 22-2003, f. 3-26-03, cert. ef. 4-1-03; OMAP 64-2004, f. 9-10-04, cert. ef. 10-1-04; DMAP 11-2007, f. 6-14-07, cert. ef. 7-1-07; DMAP 23-2009, f. 6-12-09, cert. ef. 7-1-09

410-148-0120

Reimbursement Limitations for Clients in a Nursing Facility

(1) The Division of Medical Assistance Programs (Division) will not reimburse for the following services/supplies for clients residing in a nursing facility:

(a) Nursing service visits (including assessment visit). Refer to Aging and People with Disabilities (APD) administrative rule covering all-inclusive rate;

(b) Supplies and items covered in the nursing facility All-Inclusive Rate. Refer to the Supplemental Information section of the home enteral/parenteral nutrition and IV Services provider website (http://www.dhs.state.or.us/policy/healthplan/guides/homeiv/) for a listing of those supplies and items;

(c) Oral nutritional supplements that are in addition to consumption of food items or meals.

(2) DMAP will reimburse for the following:

(a) Oral nutritional supplements are covered by the Division for nursing facility clients when medically appropriate, i.e., the client cannot consume food items or meals;

(b) Tube fed enteral nutrition formula, when medically appropriate;

(c) Patient controlled pump for pain control medication (CADD).

[Publications: Publications referenced are available from the agency.]

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: HR 26-1993, f. & cert. ef. 10-1-93; HR 34-1993(Temp), f. & cert. ef. 12-1-93; HR 11-1994, f. 2-25-94, cert. ef. 2-27-94; OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0730; OMAP 63-2003, f. 9-5-03, cert. ef. 10-1-03; OMAP 15-2004, f. 3-11-04, cert. ef. 4-1-04

410-148-0140

Billing Information

(1) For medications:

(a) Pharmacies billing electronically bill through the Division of Medical Assistance Program (Division) pharmacy benefit manager, point of sale. For more information on point of sale, contact the DMAP pharmacy benefit manager’s help desk;

(b) Only those pharmacies and Home Enteral/Parenteral Nutrition and IV (EPIV) providers billing manually for medications and home IV drug ingredients that are not billed through Point of Sale may use the CMS 1500 claim form or the 837P electronic claim form (instructions in home enteral/parenteral and IV services supplemental guide;

(c) Providers who bill by paper are required to complete a CMS 1500 claim form.

(2) For home enteral/parenteral and IV services other than medications:

(a) Providers must use the CMS 1500 form to bill for home enteral/parenteral nutrition and IV services identified with a five-digit HCPCS or CPT. Use the billing instructions found in the home enteral/parenteral nutrition and IV Services supplemental materials;

(b) See OAR 410-148-0160 for billing clients with Medicare coverage.

[Publications: Publications referenced are available from the agency.]

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: HR 26-1990, f. 8-31-90, cert. ef. 9-1-90; HR 9-1992, f. & cert. ef. 4-1-92; OMAP 7-1998, f. 2-27-98, cert. ef. 3-1-98; OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0740; OMAP 63-2003, f. 9-5-03, cert. ef. 10-1-03; DMAP 26-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 23-2009, f. 6-12-09, cert. ef. 7-1-09

410-148-0160

Billing for Clients Who Have Both Medicare and Basic Health Care Coverage

(1) The Divisin of Medical Assistance Programs (Division) may be billed directly for services provided to a client when the provider has established and clearly documented in the client's record that the service provided does not qualify for Medicare reimbursement.

(2) When the service qualifies for Medicare reimbursement, bill as follows:

(a) When billing for home enteral/parenteral nutrition services:

(A) Bill in the usual manner to the local or designated Medicare Intermediary;

(B) After Medicare makes a payment determination, bill the Division on the DMAP 505 form following the billing instructions and using the procedure codes listed for the home enteral/parenteral nutrition and IV Services in the fee schedule and supplemental materials;

(b) When billing for Home IV services:

(A) Bill the local Medicare Intermediary in the usual manner;

(B) After Medicare makes payment determination, bill DMAP following the billing instructions and using the procedure codes listed for the Home Enteral/Parenteral Nutrition and IV Services fee schedule and supplemental materials.

[Publications: Publications referenced are available from the agency.]

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: HR 9-1992, f. & cert. ef. 4-1-92; HR 26-1993, f. & cert. ef. 10-1-93; HR 3-1995, f. & cert. ef. 2-1-95; OMAP 7-1998, f. 2-27-98, cert. ef. 3-1-98; OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0750; OMAP 63-2003, f. 9-5-03, cert. ef. 10-1-03

410-148-0260

Home Enteral Nutrition

(1) Codes that have PA indicated require prior authorization. Codes with BR indicated are covered by report.

(2) Enteral nutrition formula. Use B4150 through B4156 when billing for tube fed nutritional formulae. If the product dispensed is not shown in HCPCS description, select a category equivalent when billing the Division of Medical Assistance Programs (Division).

(3) Oral nutritional supplements:

(a) Prior authorization is required on all oral nutritional supplements;

(b) Oral nutritional supplements can be billed through the on-line point of sale pharmacy system, or by paper using the CMS 1500 claim form or the electronic 837P claim form. Use the product’s NDC and HCPC code when billing the CMS 1500 or electronic 837P claim form;

(c) If the product dispensed is not shown in one of the listed categories, select a category that is equivalent when billing the Division;

(d) Oral nutritional supplements may be approved when the following criteria has been met:

(A) Clients age 6 and above:

(i) Must have a nutritional deficiency identified by one of the following:

(I) Recent low serum protein levels; or

(II) Recent registered dietician assessment shows sufficient caloric/protein intake is not obtainable through regular, liquefied or pureed foods;

(ii) The clinical exception to the requirements of (I) and (II) must meet the following:

(I) Prolonged history (i.e. years) of malnutrition, and diagnosis or symptoms of cachexia, and

(II) Client residence in home, nursing facility, or chronic home care facility, and

(III) Where (I) and (II) would be futile and invasive

(iii) Must have a recent unplanned weight loss of at least 10%, plus one of the following:

(I) Increased metabolic need resulting from severe trauma; or

(II) Malabsorption difficulties (e.g., short-gut syndrome, fistula, cystic fibrosis, renal dialysis); or

(III) Ongoing cancer treatment, advanced Acquired Immune Deficiency Syndrome (AIDS) or pulmonary insufficiency.

(iv) Weight loss criteria may be waived if body weight is being maintained by supplements due to patient’s medical condition (e.g., renal failure, AIDS)

(B) Clients under age 6:

(i) Diagnosis of ‘failure to thrive;

(ii) Must meet same criteria as above, with the exception of % of weight loss.

(4) Enteral nutrition equipment:

(a) All repair and maintenance is subject to rule 410-1480-0080;

(b) Procedure codes:

(A) S5036, Repair of infusion device (each 15 minutes = 1 unit) -- PA;

(B) B9998, Enteral nutrition infusion pump replacement parts will be reimbursed at provider’s acquisition cost (including shipping and handling);

(C) B9000, Enteral nutrition infusion pump, without alarm -- rental (1 month = 1 unit) -- PA;

(D) B9002, Enteral nutrition infusion pump, with alarm -- rental (1 month = 1 unit) -- PA;

(E) E0776, IV pole -- purchase;

(F) E0776, modifier RR, IV pole -- rental (1 day = 1 unit);

(G) S9342, Enteral nutrition via pump (1 day = 1 unit) -- PA.

(5) Home infusion therapy:

(a) S9325, Home infusion, pain management (do not use with code S9326, S9327 or S9328) -- PA

(b) S9326, Home infusion, continuous pain management -- PA;

(c) S9327, Home infusion, intermittent pain management -- PA;

(d) S9328, Home infusion, implanted pump pain management -- PA.

(6) Not Otherwise Classified (NOC):

(a) B9998, NOC for enteral supplies;

(b) S9379, Home infusion therapy, NOC -- PA/BR.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: HR 26-1990, f. 8-31-90, cert. ef. 9-1-90; HR 26-1993, f. & cert. ef. 10-1-93; HR 3-1995, f. & cert. ef. 2-1-95; OMAP 7-1998, f. 2-27-98, cert. ef. 3-1-98; OMAP 29-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0840; OMAP 22-2003, f. 3-26-03, cert. ef. 4-1-03; OMAP 63-2003, f. 9-5-03, cert. ef. 10-1-03; OMAP 15-2004, f. 3-11-04, cert. ef. 4-1-04; OMAP 52-2006, f. 12-28-06 cert. ef. 1-1-07; DMAP 23-2009, f. 6-12-09, cert. ef. 7-1-09

410-148-0280

Home Parenteral Nutrition

(1) Codes that have "PA" indicated require prior authorization. Codes with "BR" indicated are covered by report.

(2) Standard Total Parenteral Nutrition (TPN):

(a) Bill using HCPCS codes S9365 through S9368;

(b) Home infusion for stand TPN includes the following drugs and products in the per diem rate:

(A) Non-specialty amino acids (e.g., aminosyn, freeamine, travasol)

(B) Concentrated dextrose (e.g., D10, D20, D40, D50, D60, D70)

(C) Sterile water;

(D) Electrolytes (e.g., CaC12, KCL, KPO4, MgSo4, NaAc, NaCl, NaPO4);

(E) Standard multi-trace elements (e.g., MTE4, MTE5, MTE7);

(F) Standard multi-vitamin solutions (e.g., MVI-13).

(c) The following items are not included in the per diem and should be billed separately:

(A) Specialty amino acids for renal failure, hepatic failure or for high stress conditions (e.g., aminess, aminosyn-RF, nephramine, RenAmin, HepatAmine, Aminosyn-HBC, BranchAmin, FreeAmine HBC, Trophamine);

(B) Specialty amino acids with concentrations of 15% and above when medically necessary for fluid restricted patients (e.g., Aminosyn 15%, Novamine 15%, Clinisol 15%);

(C) Lipids

(D) Added trace elements, vitamins not from standard multitrace element or multivitamin solution;

(E) Products serving non-nutritional purposes (e.g., heparin, insulin, iron dextran).

(2) Parenteral Nutrition Solutions:

(a) Bill using HCPCS codes B4164 through B5200. See HCPCS book for description.

(b) Note: Reimbursement for compounding, admixture and administrative fees is included in the unit price.

(3) Parenteral Supply Kits/Supplies -- Procedure Codes

(4) Parenteral Nutrition Equipment -- Procedure Codes -- Table 0280-1.

(5) Not Otherwise Classified (NOC) -- B9999, NOC For Parenteral Supplies -- PA/BR.

[ED. NOTE: Tables referenced are available from the agency.]

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: HR 26-1990, f. 8-31-90, cert. ef. 9-1-90; HR 26-1993, f. & cert. ef. 10-1-93; HR 3-1995, f. & cert. ef. 2-1-95; OMAP 7-1998, f. 2-27-98, cert. ef. 3-1-98; OMAP 29-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0860; OMAP 22-2003, f. 3-26-03, cert. ef. 4-1-03; OMAP 15-2004, f. 3-11-04, cert. ef. 4-1-04

410-148-0300

Other Home IV and Enteral/ Parenteral Administration Services

(1) Codes that have "PA" indicated require prior authorization. Codes with "BR" indicated are covered by report.

(2) Catheter Care Kits. All catheter care kit allowable amounts are determined on a per diem basis (1 day = 1 unit):

(a) When performed as a stand alone therapy, or during days not covered under per diem by another therapy, bill using catheter care codes S5497 through S5521;

(b) The following supplies for non-routine catheter procedures may be billed separately from per diem reimbursement:

(A) S5517 Catheter declotting supply kit, 1 day = 1 unit;

(B) S5518 Catheter repair supply kit, 1 day = 1 unit;

(C) S5520 PICC insertion supply kit, 1 day = 1 unit;

(D) S5521 Midline insertion supply kit, 1 day = 1 unit.

(E) E0776 IV Pole -- Purchase.

(F) E0776 with modifier RR IV Pole -- Rental, 1 day = 1 unit

(3) Home Nursing Visits:

(a) When enteral/parenteral services are performed in the home, only a single provider of skilled home health nursing services may obtain authorization and/or bill for such services for the same dates of service;

(b) Requests made by providers for any intravenous or enteral/parenteral related skilled nursing services, either solely or in combination with any other skilled nursing services in the home are to be reviewed for prior authorization by the Division of Medical Assistance Programs (DMAP) Medical Unit;

(c) Procedure Codes:

(A) 99601, Home infusion/specialty drug administration, per visit (up to 2 hours). Modifier SS is used to indicate -- Home infusion services provided in the infusion suite of the IV therapy provider -- 1 visit = 1 unit -- PA;

(B) 99602, each additional hour. List separately in addition to code for primary procedure). Modifier SS is used to indicate -- Home infusion services provided in the infusion suite of the IV therapy provider. Use 99602 in conjunction with 99601 -- PA;

(C) T1001, Home Nursing Visit for Assessment -- 1 visit = 1 Unit.

(4) Not Otherwise Classified (NOC) -- S9379, NOC for Home IV Supplies -- PA/BR.

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: HR 26-1990, f. 8-31-90, cert. ef. 9-1-90; HR 46-1990, f. & cert. ef. 12-28-90; HR 26-1993, f. & cert. ef. 10-1-93; OMAP 7-1998, f. 2-27-98, cert. ef. 3-1-98; OMAP 29-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0880; OMAP 22-2003, f. 3-26-03, cert. ef. 4-1-03; OMAP 63-2003, f. 9-5-03, cert. ef. 10-1-03; OMAP 15-2004, f. 3-11-04, cert. ef. 4-1-04; DMAP 11-2007, f. 6-14-07, cert. ef. 7-1-07

410-148-0320

Billing Quantities, Metric Quantities and Package Sizes

(1) Use the following metric conversions when billing;

(a) Fluid Ounce -- 30 ml;

(b) Pint -- 480 ml;

(c) Quart -- 960 ml;

(d) Gallon -- 3,840 ml;

(e) Ounce (solids) -- 30 gm;

(f) Pound (solids) -- 454 gm.

(2) Use the following units when billing products:

(a) Solid substances (e.g., powders, creams, ointments, etc.), bill per gram;

(b) Solid substances that are reconstituted with a liquid (e.g., dry powder ampules and vials) such as antibiotic vials or piggybacks must be billed in metric quantity of one each;

(c) Tablets, capsules, suppositories, lozenges, packets bill per each unit. Oral contraceptives are to be billed per each table;

(d) Diagnostic supplies (e.g., chemstrips, clinitest tabs), bill per each unit;

(e) Injectables that are prepackaged syringe (e.g., tubex, carpujects), bill per ml;

(f) Medical Supplies (e.g., Testape, Cordran tape) bill in metric quantity of one each;

(g) Prepackaged medications and unit doses must be billed per unit (tablet or capsule). Unit dose liquids are to be billed by ml;

(h) Fractional ml liquid doses (e.g., flu vaccine, pneumovax, etc.) use unique codes and bill per each dose;

(i) Fractional units: If no unique codes are available, round quantity up to the next whole unit (e.g., 3.5 gm to 4.0 gm; 7.2 ml up to 8 ml).

Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.065
Hist.: HR 26-1990, f. 8-31-90, cert. ef. 9-1-90; OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0900

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