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Victims of smoke inhalation frequently suffer from both carbon monoxide and cyanide poisoning. Exocrine pancreatic insufficiency is largely diagnosed clinically, and is often identified by symptoms such as steatorrhea, weight loss, abdominal discomfort, and abdominal bloating. Using data reported in and ,the Canadian Institute for Health Information, an independent organization that works with the federal government, tabulated the input. Early versus delayed initiation of progressive enteral feedings for parenterally fed low birth weight or preterm infants. Diseases of the musculoskeletal system and connective tissue MM99 Note:

Understanding the ICD-10 Code Structure

Nutritional Support

Aetna considers intra-peritoneal amino acid IPAA supplementation medically necessary for members on peritoneal dialysis when all of the following criteria are met:. If the criteria for parenteral nutrition are met, medically necessary nutrients, administration supplies, and equipment are considered medically necessary. Aetna covers special medical foods only when mandated by state law. Special medical foods are used for the treatment of inborn errors of metabolism histidinemia, homocystinuria, maple syrup urine disease [MSUD], phenylketonuria [PKU], and tyrosinemia.

The special oral formulas are designed to restrict intake of one or more amino acids. Some states now have mandates requiring coverage of these dietary formulas. Food supplements, specialized infant formulas e. Most Aetna plans do not specifically include coverage of infant formulas when taken orally.

In the absence of a specific inclusion or state mandate, specialized infant formulas are not covered. In most instances, the central venous route is utilized, and for long-term total parenteral nutrition a central catheter e. Enteral nutrition can be administered via a small catheter placed through the nose into the stomach or by a surgically placed catheter into the stomach or intestines.

Enteral nutrition therapy may supplement protein and calories in a variety of situations where oral nutrition is not adequate, with the intention of providing part or all of the daily requirements. Specialized diets for specific diseases or pathophysiologic situations may be administered via enteral nutrition. These specialized diets may involve restricting a particular element of the diet e.

The need for specialized foods is very common, and for most conditions, the specialized food is needed for the person's entire lifetime. There are many other examples where specialized diets are prescribed, which could extend to specialized diets for hypertension, diabetes, or cardiovascular disease.

Sullivan et al evaluated the health benefits of an exclusively human milk-based diet compared with a diet of both human milk and bovine milk-based products in extremely premature infants. Infants fed their own mothers' milk were randomized to 1 of 3 study groups. Outcomes included duration of parenteral nutrition, morbidity, and growth. The authors concluded that for extremely premature infants, an exclusively human milk-based diet is associated with significantly lower rates of NEC and surgical NEC when compared with a mother's milk-based diet that also includes bovine milk-based products.

The average NICU costs for an extremely premature infant without NEC and the incremental costs due to medical and surgical NEC were derived from a separate analysis of hospital discharges in the state of California in The sensitivity of cost-effectiveness results to the risks and costs of NEC and to prices of milk supplements was studied. Relizorb is considered a first of it's kind enzyme cartridge. However, large scale studies in human subjects are still lacking.

Therefore, there is an insufficient evidence base to support its use at this time. Schwarzenberg and associates stated that nutrition is integral to the care of individuals with cystic fibrosis CF. Better nutritional status is associated with improved pulmonary function. In some individuals with CF, enteral tube feeding can be useful in achieving optimal nutritional status.

Current nutrition guidelines do not include detailed recommendations for enteral tube feeding. The Cystic Fibrosis Foundation convened an expert panel to develop enteral tube feeding recommendations based on a systematic review of the evidence and expert opinion. These guidelines addressed when to consider enteral tube feeding, assessment of confounding causes of poor nutrition in CF, preparation of the patient for placement of the enteral feeding tube, management of the tube after placement and education about enteral feeding.

These recommendations are intended to guide the CF care team, individuals with CF, and their families through the enteral tube feeding process.

The guideline stated that an inline cartridge enzyme lipase delivery system for enteral feeds was approved by the FDA for adults during the development of these guidelines; evaluation of its benefits and limits should be considered before use. In a multi-center, randomized, double-blind, cross-over, open-label clinical trial, Freedman and colleagues evaluated the safety, tolerability, and fat absorption of a new in-line digestive cartridge Relizorb that hydrolyzes fat in enteral formula provided to patients with CF.

Plasma omega-3 fatty acid FA concentrations were measured and used as markers of fat absorption. Gastro-intestinal symptoms were recorded to evaluate safety and tolerability. Information regarding the effect of enteral nutrition EN on appetite and breakfast consumption was also collected. Before study entry, participants had received EN for a mean of 6. Compared with placebo, cartridge use resulted in a statistically significant 2. There were no adverse experiences associated with cartridge use, and a decrease in the frequency and severity of most symptoms of malabsorption was observed with cartridge use.

Participants reported increased preservation of appetite and breakfast consumption with cartridge use compared with their pre-study regimen. The authors concluded that the use of this in-line digestive cartridge was safe and well-tolerated, and resulted in significantly increased levels of plasma omega-3 FA used with enteral formula, suggesting an overall increased fat absorption. In addition, the age range of the study population is representative of the population of patients with CF in the United States.

Thus, these study results should be generalizable to the larger population of patients with CF and exocrine pancreatic insufficiency who receive supplemental EN.

Only 1 feeding through digestive cartridge was, however, used to measure its effect on fat absorption, and only 7 days of digestive cartridge use were used to measure its safety. They stated that a longer-term study is currently ongoing to assess the effects of sustained digestive cartridge use, particularly without concomitant pancreatic enzyme replacement therapy.

Alkaade and Vareedayah stated that exocrine pancreatic insufficiency EPI is characterized by a deficiency of exocrine pancreatic enzymes, resulting in deficits in digestion of all macronutrients, with deficiencies in digestion of fats being the most clinically relevant.

The leading cause of EPI is chronic pancreatitis. However, many other causes and conditions may be implicated, including CF, pancreatic duct obstruction, gastric and pancreatic surgery, diabetes mellitus and other conditions.

Physical and biochemical causes of EPI include decreased production and secretion of lipase, increased lipase destruction, pancreatic duct obstruction, decreased lipase stimulation and degradation, as well as gastro-intestinal GI motility disorders.

Exocrine pancreatic insufficiency is largely diagnosed clinically, and is often identified by symptoms such as steatorrhea, weight loss, abdominal discomfort, and abdominal bloating. Nutrient utilization may be improved using semi-elemental or elemental enteral products or dosing pancreatic enzyme replacement therapy PERT with enteral feedings. Additionally, a recently approved in-line medical device with immobilized lipase Relizorb has been developed to hydrolyze fats in enteral formula.

Nguyen noted that EN is preferred over parenteral nutrition PN as a result of the greater safety of EN therapy and comparative convenience. A wide variety of EN products have been developed, including disease-specific products to help manage the nutritional needs of patients with kidney failure, liver failure, lung disease, diabetes, and other conditions.

An assessment of each patient's nutritional needs and digestive function should be conducted prior to initiation of EN therapy. Other considerations in determining the appropriate route and method of EN administration include the time and nursing involvement required for administration, potential complications of medication administration, and concerns related to pancreatic dysfunction in certain groups. The author noted that i a recently approved in-line medical cartridge with immobilized lipase Relizorb hydrolyzes fats in enteral formulas just prior to delivery into the patient with an enteral feeding tube; and ii to eliminate the challenges of PERT administration, the Cystic Fibrosis Foundation indicates Relizorb may be used to deliver enteral formula in this population.

Freedman stated that patients with EPI have suboptimal secretion of pancreatic digestive enzymes and experience a range of clinical symptoms related to the malabsorption of fat. In patients with EPI unable to meet their nutritional requirements, EN support is used to augment nutritional status.

In addition to protein and carbohydrate, EN formulas contain fats as a calorie source, as well as vitamins and minerals to help prevent nutritional deficiencies related to malabsorption.

Semi-elemental EN formulas are advantageous as they contain hydrolyzed protein, shorter chain carbohydrates, and may contain medium chain triglycerides as a fat source. However, severely pancreatic insufficient patients may be unable to absorb complex long-chain triglycerides provided by EN formulas due to insufficient pancreatic lipase; replacement pancreatic enzyme products are recommended for these patients.

Currently, none of the FDA-approved PERT products are indicated for use in patients receiving EN and administration of enzymes by mixing into EN formula is not supported by guidelines as this route is associated with risks. Relizorb immobilized lipase is a novel in-line digestive cartridge that has been designed to address the unmet need for PERT in patients receiving EN. Relizorb efficacy and compatibility with a range of commercially available polymeric and semi-elemental formulas with varying nutrient, caloric content, and triglyceride chain lengths have been demonstrated.

Aetna's policy on parenteral and enteral nutrition is similar to Medicare policy. Medicare provides reimbursement under the part-B prosthetic-device benefit for parenteral and enteral nutrition.

Consistent with its policy of covering supplies necessary for use of prosthetics, Medicare will generally cover medically necessary supplies, equipment, and nutrients associated with parenteral and enteral nutrition if the coverage requirements for enteral or parenteral nutritional therapy are met under the prosthetic device benefit provision. Clinical Policy Bulletin Notes. Links to various non-Aetna sites are provided for your convenience only. Enteral Tube Feedings Enteral nutrition is the provision of nutritional requirements through a tube into the stomach or small intestine.

Equipment Appropriate nutrients, administration supplies, and equipment are considered medically necessary for persons who meet criteria for enteral feedings. Relizorb Relizorb is considered experimental and investigational for use with enteral tube feedings due to insufficient evidence in the peer-reviewed literature.

Aetna considers parenteral nutrition medically necessary for members who meet any of the following criteria: A condition in which it is necessary for the gastrointestinal tract to be totally non-functioning for a period of time;.

Evidence of structural or functional bowel disease that makes oral and tube feedings inappropriate;. Hyperemesis gravidarum only in cases of failed medical management or when used in a step-therapy program ;. A physical disorder impairing food intake such as the dyspnea of severe pulmonary or cardiac disease;. Enteral and parenteral nutrition therapy covered as prosthetic device. Medicare Coverage Issues Manual Section CMS; effective July 11, Medicare Local Medical Review Policy.

Tricenturion; effective July 1, Tricenturion; effective April 1, The acceptability of milk and milk products in populations with a high prevalence of lactose intolerance. Am J Clin Nutr. Nutritional support in the critically ill patients. A critical review of the evidence. An overview of current practice. Outcome of long-term enteral feeding. Gastrointest Endosc Clin N Am. Gastroenterol Clin North Am. Evaluation of outcomes for patients with AIDS receiving home total parenteral nutrition.

Enteral and parenteral nutrition transitioning from hospital to home. Howard L, Hassan N. Enteral nutrition in gastrointestinal disease. Parenteral nutrition use at a university hospital and development of a practice guideline algorithm. Parenteral nutrition support in patients with cancer.

Perioperative total parenteral nutrition in surgical patients. N Engl J Med. Parenteral nutrition in patients receiving cancer chemotherapy - American College of Physicians Position Paper. American Academy of Pediatrics Committee on Nutrition. Reimbursement for medical foods for inborn errors of metabolism. Enteral versus parenteral nutrition in acute pancreatitis.

Enteral versus parenteral nutrition. Enteral and parenteral nutrition in the seriously ill, hospitalized patient: J Nutr Health Aging. Special formulas in infant nutrition: Prevention of allergies of infants: Breast-feeding and special formulas. Influence on the response to immunization. Acta Biomed Ateneo Parmense. Nutrition Counseling and Follow-up. An evidence-based evaluation of intradialytic parenteral nutrition. Am J Kidney Dis. Intradialytic parenteral nutrition for hemodialysis patients.

Health Technology Review No. Curr Opin Crit Care. American Gastroenterological Association medical position statement: Howard L, Ashley C.

Nutrition in the perioperative patient. Diagnosis of dysphagia and its nutritional management for stroke patients. NIH; updated August 18, Accessed October 29, Prevalence of celiac disease in at-risk and not-at-risk groups in the United States: All codes require a decimal after the third 3rd character. Laterality side of the body affected is required or certain codes.

If a code requires laterality, it must be included in order for the code to be valid. As a general rule: The number 1 is used to indicate right side. The number 2 is used to indicate left side.

The number 9 indicates side is unspecified in the medical record. Addition of 7th character - required for certain codes, including 'S' codes injuries and external causes , to provide information about the characteristic of the encounter. When required, one of the following alpha digits must be used in the 7th position for the code to be considered valid. When a placeholder character applies, it must be used in order for the code to be considered valid. S52 Fracture of forearm.

In the above example, S52 is the category. The fourth and fifth characters of "5" and "2" provide additional clinical detail and anatomic site. The sixth character 1 indicates laterality, i. The seventh character, "A", is an extension which, in this example, means "initial encounter". The 5th and 6th character sub-classification represent the most accurate level of specificity.

All ICD codes will begin with one of the following letters of the alphabet; the alpha characters are not case sensitive. The most commonly reported diagnoses for chiropractic are likely to begin with an "M" or an "S". Infectious and Parasitic Diseases. Neoplasms, Blood, Blood-forming Organs.

Mental and Behavioral Disorders. Eye and Adnexa, Ear and Mastoid Process. Skin and Subcutaneous Tissue. Musculoskeletal and Connective Tissue. Pregnancy, Childbirth and the Puerperium. Certain Conditions Originating in the Perinatal Period.