Infusion Referrals
Information Required for Infusion Referrals:
- Allergies
- Anticipated start-of-care date
- Medication / dosage (must have hard copy Rx)
- First dose
- Frequency
- Height & weight
- IV access / catheter type (PICC line, portacath, hep well, etc) insertion date, number of ports
- Length of treatment
- Medication profile
- Patient / caregiver support / participation
Infusion Options:
- Antibiotics
- Chemotherapy
- Hydration
- Inotropic
- IVIG
- Total Parenteral Nutrition (TPN)
- Pain management
- Steroids
Medicare Coverage Requirements for TPN:
A) Short bowel/gut less than 5 feet:
- Complete bowel obstruction
- GI fistula with output greater than 500ml/day
- Malnutrition / enteral trial failed or not feasible
AND/OR
B) Prolonged bowel rest necessitated by:
- IBD (inflammatory bowel disease, i.e. Chrons’ disease)
- Pancreatitis
Qualifying Documentation for TPN:
- History & physical
- Nutritional assessment
- Serum albumin
- Current TPN formula
- Discharge summary
- Operative report
- Details of failed enteral trial
- Details of prokinetic medications, etc.
- Fecal fat test
- Medications
- Physician letter of medical necessity
- Small bowel motility studies
- X-rays
Insurance verification is completed by AHC for all payors.
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