Enteral Nutrition - Correct Coding and Billing - JA DME

Joint DME MAC Article
Posted October 8, 2020

This Correct Coding and Billing publication is effective for claims with dates of service on or after November 12, 2020.

Enteral nutrition is covered under the Prosthetic Device benefit (Social Security Act § 1861(s)(8)). In order for a beneficiary’s nutrition to be eligible for reimbursement the reasonable and necessary (R&N) requirements set out in the National Coverage Determinations (NCD) Manual (CMS Pub. 100-03), Chapter 1, Section 180.2 must be met. In addition, there are specific regulatory, payment and coding requirements, discussed below, that also must be met.

Enteral nutrition products that are administered orally and related supplies are noncovered; no benefit.

If the coverage requirements for enteral nutrition are met, medically necessary nutrients, administration supplies and equipment are covered.

Enteral nutrition provided to a beneficiary in a Part A covered stay must be billed by the Skilled Nursing Facility (SNF) to the A/B MAC. No payment from Part B is available when enteral nutrition services are furnished to a beneficiary in a stay covered by Part A. However, if the stay is not covered by Part A, enteral nutrition may be eligible for coverage under Part B and may be billed to the DME MAC, by either the SNF or an outside supplier.

GENERAL DOCUMENTATION REQUIREMENTS

In order to justify payment for DMEPOS items, suppliers must meet the following requirements:

• Standard Written Order (SWO)
• Medical Record Information (including continued need/use if applicable)
• Correct Coding
• Proof of Delivery

NUTRIENTS

Food thickeners (B4100), baby food, and other regular grocery products that can be blenderized and used with the enteral system will be denied as noncovered.

Codes B4102 and B4103 describe electrolyte-containing fluids that are noncovered by Medicare.

Self-blenderized formulas are noncovered by Medicare.

Code B4104 is an enteral formula additive. The enteral formula codes include all nutrient components, including vitamins, mineral, and fiber. Therefore, code B4104 will be denied as not separately payable.

SUPPLIES

The unit of service (UOS) for the supply allowance (B4034, B4035, or B4036) is one (1) UOS per day.

Claims that are submitted for more than one UOS per day for HCPCS codes B4034, B4035, or B4036 will be rejected.

DME INFORMATION FORM (DIF)

A DME Information Form (DIF) which has been completed, signed, and dated by the supplier, must be kept on file by the supplier and made available upon request.

The DIF for Enteral Nutrition is CMS Form 10126. The initial claim must include an electronic copy of the DIF.

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, or
• Enteral nutrition services are resumed after they have not been required for two consecutive months.

A new initial DIF for a pump (B9002) is required when:

• Enteral nutrition services involving use of a pump are resumed after they have not been required for two 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 is changed, or
• The number of days per week administered is changed, or
• The method of administration (syringe, gravity, pump) changes, or
• The route of administration is changed from tube feedings to oral feedings (if billing for denial), or
• The HCPCS code for the current nutrient changes

A revised DIF must be submitted when the length of need previously entered on the DIF has expired and the treating practitioner is extending the length of need for the item(s).

Special nutrient formulas, HCPCS codes B4149, B4153, B4154, B4155, B4157, B4161, and B4162, are produced to meet unique nutrient needs for specific disease conditions. The beneficiary's medical record must adequately document the specific condition and the need for the special nutrient. This information shall be available upon request.

If two enteral nutrition products, which are described by the same HCPCS code, are being provided at the same time, they should be billed on a single claim line, with the units of service reflecting the total calories of both nutrients.

CODING GUIDELINES

Enteral feeding supply allowances (B4034, B4035, and B4036) include all supplies, other than the feeding tube and nutrients, required for the administration of enteral nutrients to the beneficiary for one day. Only one unit of service may be billed for any one day. Codes B4034, B4035, and B4036 describe a daily supply fee rather than a specifically defined "kit." The use of individual items may differ from beneficiary to beneficiary, and from day to day. Items included in these codes are not limited to pre-packaged "kits" bundled by manufacturers or distributors. These supply allowances include, but are not limited to, a catheter/tube anchoring device, feeding bag/container, flushing solution bag/container, administration set tubing, extension tubing, feeding/flushing syringes, gastrostomy tube holder, dressings (any type) used for gastrostomy tube site, tape (to secure tube or dressings), Y connector, adapter, gastric pressure relief valve, declogging device. These items must not be separately billed using the miscellaneous code (B9998), or using a specific code for any individual item, should a unique HCPCS code for the item exist.

The following Coding Guidelines apply for billing of In-Line Cartridges for enteral feeding:

Effective for dates of service on or after July 1, 2018 through July 12, 2018, code Q9994 (IN-LINE CARTRIDGE CONTAINING DIGESTIVE ENZYME(S) FOR ENTERAL FEEDING, EACH) is the code used to bill for in-line digestive enzyme cartridges. For these dates of service, code Q9994 is not payable by Medicare.

Effective for dates of service on or after July 13, 2018 through December 2, 2018, code Q9994 (IN-LINE CARTRIDGE CONTAINING DIGESTIVE ENZYME(S) FOR ENTERAL FEEDING, EACH) is the code used to bill for in-line digestive enzyme cartridges. For these dates of service, code Q9994 is not separately billable and is included in the supply allowance for enteral feeding supplies (see section 30.7.2 of the Medicare Claim Processing Manual (Internet Only Manual (IOM) 100-4), Chapter 20, "Payment for Parenteral and Enteral Nutrition (PEN) Items and Services.")

Effective for dates of service on or after December 3, 2018 through December 31, 2018, claims for code Q9994 are eligible for separate payment.

Effective for dates of service on or after January 1, 2019, code Q9994 is crosswalked to code B4105 (IN-LINE CARTRIDGE CONTAINING DIGESTIVE ENZYME(S) FOR ENTERAL FEEDING, EACH). Claims for code B4105 are eligible for separate payment.

When an IV pole (E0776) is used for enteral nutrition administered by gravity or a pump, the BA modifier should be added to the code. Code E0776 is the only code with which the BA modifier may be used.

When enteral nutrients (B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, and B4162) are administered by mouth, the BO modifier must be added to the code. Products that are only administered orally should be coded as A9270.

Code B4149 describes formulas containing natural foods that are blenderized and packaged by a manufacturer. B4149 formulas are classified based upon this manufacturer requirement, not on the composition of the enteral formula. Code B4149 must not be used for foods that have been blenderized by the beneficiary or caregiver for administration through a tube.

The only products which may be billed using codes B4149, B4153, B4154, B4155, B4157, B4161, or B4162 are those for which a written Coding Verification Review has been made by the Pricing, Data Analysis and Coding (PDAC) Contractor and subsequently published on the appropriate Product Classification List.

Suppliers should refer to the Enteral Nutrition Product Classification list on the PDAC Contractor website or contact the PDAC for guidance on the correct coding for these items.

HCPCS CODES:

Group 1 Codes:

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