Ch 38: Home Nutrition Support

Question 1

Most insurance companies require home nutrition support to be what?

Answer 1

Medically necessary and the sole source of nutrition

Government payers and insurers who follow the Medicare coverage criteria may require substantiation of needed over time

Question 2

EN and PN are primarily covered under which benefit under Medicare part B program?

Answer 2

Prosthetic device benefit
This provision requires a permanent dysfunction of a body organ. Medicare requires therapy to be reasonable and necessary for diagnosis or treatment of illness or injury to improve the functioning of a malformed body part

Question 3

In Medicare terms, how long is a permanent condition?

Answer 3

At least 3 months

Question 4

Per Medicare, what type of formula is considered appropriate for most patients requiring HEN?

Answer 4

Standard polymetric

Additional documentation needed for specialty produces. Clinicians should be aware that not all formulas w/in Medicare coverage category are clinically equivalent or interchangeable, though they may be reimbursed at the same rate

Question 5

What are the suggested lab panels that should be monitored with home PN?

Answer 5

Suggested lab panels to evaluate include BMP, hepatic function panel, plasma proteins, complete bood count mg, and phos

Question 6

How often should labs be checked for home PN patients?

Answer 6

Initially, labs should be done one/week for 4 weeks or until values are stable. Once stable, lab monitoring may be shifted to once/month

Trace elements, vitamins, and phospholipid FA profile should be checked every 3-12 months with more frequent monitoring for patients with know deficiencies, or toxicities or when national shortages of IV trace elements, vitamin, or lipids occur

Question 7

• Soybean oil-based ILE should provide less than____ g fat per kg body weight per day

Answer 7

less than 1 g fat per kg body weight per day

Question 8

For home PN patients, how often should bone mineral testing be done?

Answer 8

Bone mineral testing should be done annually

PN patients should be monitored for iron deficiency b/c iron not routinely added to PN; serum trace should be monitored every 3-12 months to prevent deficiency and toxicity

Question 9

Which agency accredits home care companies?

Answer 9

The Joint Commission

Question 10

Following initial certification of parenteral nutrition by Medicare, after what length of time is recertification required?

Answer 10

6 months

After initial certification for parenteral nutrition is obtained, recertification is required after 6 months of therapy. The recertification process is used to document the patient’s continued need for therapy; additional recertifications may be requested on an individual basis.

Question 11

What conditions must be met for a patient to qualify as a beneficiary for home EN under Medicare Part B?

Answer 11

Home enteral nutrition is a covered Medicare Part B benefit for a patient who has a permanent condition or disorder (>90 days) that impairs food from reaching the small bowel or disease of the small bowel that impairs digestion and absorption of adequate nutrition.

The beneficiary must require tube feeding to provide adequate nutrients to maintain weight and strength to align with their overall health status. The patient’s condition could be either anatomic, e.g. obstruction due to head and neck cancer or reconstructive surgery, or due to a motility disorder, e.g. severe dysphagia following a stroke. Enteral nutrition is not covered for patients with a functioning gastrointestinal tract whose need for enteral nutrition is due to reasons such as anorexia, malnutrition, or nausea.

Question 12

Medicare reimbursement for home and community-based professional nutrition education services provided by a registered dietitian is restricted to patients who have which diagnosis/situations?

Answer 12

Diabetes, pre-dialysis kidney disease, and those who previously had a kidney transplant.

Question 13

Managed care and private insurance companies often use which established criteria/guidelines when approving coverage for home parenteral nutrition (HPN)?

Answer 13

Medicare criteria

Question 14

Patient education materials for home enteral and parenteral nutrition patients should be written at what grade level?

Answer 14

5th or 6th

Question 15

The maximum hang time an open system enteral feeding formulation container in the home setting is home long?

Answer 15

12 hours

Open system enteral feeding containers should have a hang time of no more than 12 hrs at home and 8 hrs in the hospital. Open system enteral feeding containers are more likely to be exposed to contaminants

Question 16

Initially, how often should electrolytes be monitored in a patient on home parenteral nutrition support?

Answer 16

Weekly; A.S.P.E.N. recommends weekly monitoring of serum glucose, electrolytes, blood urea nitrogen, creatinine, magnesium and phosphorus for four weeks or until the patient is clinically stable

Question 17

Which types of vascular access devices are approved for home PN administration?

Answer 17

Tunneled central venous catheters, implanted ports, peripherally inserted central catheters.

Question 18

According to the Centers for Medicare and Medicaid Services, which criteria should be met as an indication for home parenteral nutrition?

Answer 18

Documented evidence of inability to tolerate feeding through the enteral route.

Typically, HPN is covered for patients with less than or equal to 5 feet of small bowel beyond the ligament of Treitz; gastrointestinal losses exceeding 50% of oral intake (2.5 to 3 liters per day in and > 1.25 to 1.5 L/day out). Bowel rest is required for at least 90 days and 20-35 calories per kilogram (kg) per day is prescribed.

Question 19

Third-party payors (insurance companies) are LEAST likely to reimburse which of the following home enteral nutrition expenses?

Answer 19

Enteral formula

Many third-party payors equate the costs of enteral formulas to “ groceries” and do not cover this expense, while they will cover the costs of an enteral pump and supplies.

Formula is covered under Medicare Part B, but the patient will be financially responsible for 20% of the Medicare approved amount. If the patient has a supplement or secondary insurance, it will usually pick up the 20% that Medicare does not cover.

Question 20

To meet the Medicare payor criteria for home enteral or parenteral nutrition, the patient’s condition must be considered to be “of long and indefinite duration”. Which length of time meets Medicare’s test of permanence requirement?

Answer 20

> 90 days

Question 21

Home-prepared or blenderized enteral nutrition (EN) formulations should be discarded after how long?

Answer 21

24 hours; The use of home-prepared or blenderized EN formulations requires additional attention to nutrient content and safe food handling and storage practices. These formulas should be discarded after 24 hours. Hang time for blenderized or reconstituted formula is 4 hrs.

Question 22

All patients on PN greater than one year should be screened for what?

Answer 22

Metabolic bone disease; Bone mineral testing (DEXA) should be done annually.

Question 23

Which conditions increase the risk of aluminum toxicity in patients on long term PN?

Answer 23

Renal failure and iron deficiency anemia

Question 24

A 70% ethanol lock (ELT) solution removes what inside a VAD?

Answer 24

Luminal biofilm in which microorganisms are harbored

ELT increases breakage and thrombosis and weakens VADs made from polyurethane. Ethanol is incompatible with heparin.