by Medicare Learning Network
March 9th, 2018
The Medicare Learning Network provides guidance on required documentation for enteral nutrition.
Medicare covers enteral nutrition for a beneficiary who has:
- (a) Permanent non-function or disease of the structures that normally permit food to reach the small bowel
- (b) Disease of the small bowel which impairs digestion and absorption of an oral diet, either of which requires tube feedings to provide sufficient nutrients to maintain weight and strength proportionate with the beneficiary’s overall health status
Keep the following coverage requirements in mind when submitting a claim to Medicare for enteral nutrition:
- Medicare pays for no more than 1 month’s supply of enteral nutrients at any one time
- If the claim involves an infusion pump, it must be supported by sufficient medical documentation to establish that the pump is medically necessary. Program payment for the pump is based on the reasonable charge for the simplest model that meets the medical needs of the patient as established by medical documentation
- The enteral nutrition must be infused seven days per week. Documentation requirements include a detailed written order (DWO) for each item billed that must be signed and dated by the treating physician and a DME Information Form (DIF), which has been completed, signed, and dated by the supplier. Both of these must be kept on file by the supplier and made available upon request.
A new initial DIF for enteral nutrients is required when:
- A formula billed with a different code, which has not been previously certified, is ordered
- Enteral nutrition services resume after they have not been required for 2 consecutive months, or
- A beneficiary receiving enteral nutrition by the syringe or gravity method is changed to administration using a pump.
A revised DIF for enteral nutrients is required when:
- The number of calories per day changes
- The number of days per week administered changes
- The method of administration (syringe, gravity, pump) changes
- The route of administration changes from tube feedings to oral feedings (if billing for denial)
- The HCPCS code for the current nutrient changes
Consider formula specific coverage requirements when billing Medicare for enteral nutrition:Enteral formulas consisting of semi-synthetic intact protein/protein isolates (B4150 or B4152) are appropriate for the majority of beneficiaries requiring enteral nutrition
- For each beneficiary, justify the medical necessity for special enteral formulas (B4149, B4153-B4155, B4157, B4161, and B4162)
- If a special enteral nutrition formula is provided and if the medical record does not document why that item is medically necessary, it will be denied as not reasonable and necessary