Enteral and Parenteral Nutrition - JA DME
Enteral and Parenteral Nutrition
Coverage and Documentation
- Standard Documentation Requirements for All Claims Submitted to DME MACs
- Clinician Letter - Medical Records [PDF]
Enteral Nutrition
- Local Coverage Determination (LCD)
- Policy Article
- Clinician Checklist [PDF]
- Clinician Letter - CERT [PDF]
- Documentation Checklist [PDF]
Accessories
More than three nasogastric tubes (B4081, B4082, and B4083) or one gastrostomy/jejunostomy tube (B4087 or B4088) every three months is not medically necessary.
Billing
If two enteral nutrition products, which are described by same HCPCS code, are being provided at same time, bill on a single claim line with units of service reflecting total calories of both nutrients.
If coverage requirements for enteral nutrition are met, medically necessary nutrients, administration supplies and equipment are covered.
Formulas
Enteral formulas consisting of semi-synthetic intact protein/protein isolates (B4150 or B4152) are appropriate for a majority of beneficiaries requiring enteral nutrition.
For special enteral formulas (B4149, B4153, B4154, B4155, B4157, B4161, and B4162) medical necessity must be justified for each beneficiary as to why this special formula is needed versus semi-synthetic enteral formula.
Pumps
If an enteral pump (B9002) is ordered, there must be sufficient documentation in the beneficiary's medical record to justify its use. Examples of statements showing medical necessity would be "gravity feeding is not satisfactory due to reflux"; "aspiration"; "severe diarrhea"; "dumping syndrome"; "administration rate less than 100ml/hr"; "blood glucose fluctuations"; "circulatory overload; or "gastrostomy/jejunostomy tube used for feeding". If medical necessity of the pump is not documented, the pump will be denied.
Supply Kit Fee/Allowance
The enteral feeding supply kit is a daily feeding supply fee/allowance, and includes all supplies, other than the feeding tube and nutrients, required for the administration of enteral nutrients to the beneficiary for one day. The supply needs will vary between beneficiaries.
Enteral feeding supply kits (B4034, B4035, B4036, and B4148) are specific to the route of administration and submission of a claim for more than one type of kit code delivered on same date or provided on an ongoing basis will be denied as not medically necessary.
Parenteral Nutrition
- Local Coverage Determination (LCD)
- Nutrition Policy Article
- Clinician Checklist [PDF]
- Documentation Checklist [PDF]
Pumps
Only one infusion pump (B9004, B9006) is covered for beneficiaries in whom parenteral nutrition is required.
Supply Kit Fee/Allowance
Parenteral supply allowances (B4220, B4222 and B4224) allow only one supply kit and one administration kit for each day parenteral nutrition is administered. This a daily supply fee rather than a specifically defined "kit" and include all supplies required for the administration of parenteral nutrition to the beneficiary for one day.
Reviews/Audits
- Medical Review - View notifications/findings of pre/post claim reviews completed by Noridian Medical Review
Tips
Billing
It is possible for Medicare to have records on file that contain different information than in supplier records. This could result in payments that are not in an amount expected by the supplier. It is imperative that suppliers keep current records on file to properly reflect current provision of nutrition. Denials must follow the appeals process.
Payment Categories
Pumps
The reasonable useful lifetime (RUL) is considered eight years for parenteral/enteral pumps. Replacement may be considered with appropriate documentation.
Modifiers
Maintenance and Service
- MS - Pump Maintenance and Service
- Enteral: One-half rental payment may be paid every six months, six months after last rental month
- Parenteral: One-half rental payment may be paid every three months, three months after last rental month
Nutrition/Supplies
- BA - Item(s) furnished in conjunction with parenteral enteral nutrition services (gravity or pump administered nutrition)
- BO - Orally administered enteral nutrition (noncovered)
Policy-Specific
- EY - No physician or other healthcare provider order on file (not reasonable and necessary)
- KX - All coverage criteria in the "Coverage Indications, Limitations, and/or Medical Necessity" section in the related LCD have been met
- Required for use on claims with date of service July 2, 2023, and after
- GA - Policy criteria is not met. Waiver of Liability statement on file. Valid Advance Beneficiary Notice of Noncoverage (ABN) obtained
- Required for use on claims with date of service July 2, 2023, and after, if the KX modifier does not apply, and a valid ABN is received
- GZ - Item or service expected to be denied as not reasonable or necessary, no valid ABN on file. (Automatically denied/not subject to complex medical review)
- Required for use on claims with date of service July 2, 2023, and after
- KX, GA, GY modifiers do not apply
- GY - Item or service statutorily excluded or does not meet the definition of any Medicare benefit
- Required for use on claims with date of service July 2, 2023, and after
- KX, GA, GZ modifiers do not apply
- 99 - Modifier overflow - When more than four modifiers are required to describe a service on the same code, replace the fourth modifier with modifier 99
Pumps
- RR - Pump rental
- NU - New pump purchase
- UE - Purchase of used pump
- KH - Initial claim, first month pump rental
- KI - Second and third month pump rental
- KJ - Rental months four to fifteen
Purchase Option
- BP - Beneficiary selected purchase option
- Append to pump before month 10
- Example: B9002NUKXBP
- BR - Beneficiary selected rental option
- Append to pump before month 10
- B9004RRKHKXBR
- BU - Beneficiary did not inform supplier of decision
