Coding for TPN-Total Parenteral Nutrition

Total Parenteral Nutrition (TPN) is the administration of nutrients to a patient through a central line, when the patient is unable to receive a sufficient amount of nutrients by eating or is unable to receive nutrients orally.

Many home health care plans for TPN patients include orders for lab draws as well as the administration of the nutrient rich solution. In order to accurately capture the skilled interventions provided by SN, the coder should list the following for TPN patients when applicable:

V58.81 Attn Vascular Catheter (captures the care of the venous line and administration)

V58.83 Drug Monitoring (lab draws)

V58.69 LT Current Drug Use (Nutrient rich solution drug)

PPS OASIS item: M1030 Therapies the patient receives at home should be marked as 2-Parenteral Nutrition (TPN or liquids)

Therapeutic Drug Monitoring: V58.83

Many times, clinicians have orders to draw labs to monitor drug levels, in order to capture the lab draws for drug monitoring, V58.83 Encounter for Therapeutic Drug Monitoring is used. When listing V58.83 an additional code from V58.61 – V58.69 should be used to indicate the type of drug that is being monitored.  Encounter of Therapeutic Drug Monitoring (V58.83) should not be used as a primary diagnosis for a home health patient. V58.83 code is not used for simple medication management nor for filling a medication box.  Coders should only use V58.83 therapeutic drug monitoring when the clinician is assessing the effectiveness of a medication through lab information.

Example 1:  A patient has a diagnosis of DVT and is on Coumadin therapy, skilled nurse is drawing blood for PT/INRs.

M1020a:DVT – 453.40

M1022b:Encounter for drug monitoring – V58.83

M1022c: LT use (current) anticoagulants – V58.61

Rationale: DVT is listed as the primary diagnosis as this is the diagnosis requiring Coumadin. Since the nurse is drawing blood for PT/INRs, V58.83 Encounter for Therapeutic Drug Monitoring is listed, as well as the type of drug being monitored, in this case Coumadin, an anticoagulant.

Example 2:  A patient has a diagnosis of acute osteomyelitis of the foot. The patient has a PICC line in which vancomycin is being administered for 6 weeks.  Skilled nurse to draw labs weekly for vanco trough levels.

M1020a: Acute Osteomyelitis of foot – 730.07

M1022b: Therapeutic drug monitoring – V58.83

M1022c:  LT use (current) antibiotics – V58.62

M1022d: Attention vascular device – V58.81

Rationale: Acute Osteomyelitis of foot is listed as the primary diagnosis as this is the diagnosis requiring Vancomycin. Since the nurse is drawing blood for troughs, V58.83 Encounter for Therapeutic Drug Monitoring is listed, as well as the type of drug being monitored, in this case Vancomycin, an antibiotic.

Long-term (current) drug use codes V58.61- V58.69 can only be used as secondary codes and should not be used for simple medication monitoring.  The words “long term” can be a little misleading as there is no official definition for long term.   These codes are to be used if the medication shows to be an important aspect of the plan of care or if the coding guidelines require the use of the code,  e.g. insulin use for a diabetic patient.

V58.61 LT use of anticoagulants (Coumadin, Warfarin, Enoxaparin, Pradaxa)

V58.62 LT use antibiotics (Vancomycin, Cubicin)

V58.63 LT use antiplatelets/antithrombotics (Plavix)

V58.64 LT use non-steroidal anti-inflammatories (NSAID)

V58.65 LT use steroids (Prednisone)

V58.66 LT use aspirin (ASA)

V58.67 LT use insulin (Levemir, Lantus)

V58.68 LT use bisphosphonates *NEW* (Reclast, Fosamax, Boniva, Actonel)

V58.69 LT use of other medications (use for B12, Dilantin, Digoxin)