Article Detail - JD DME
Enteral Nutrition - Documentation Requirements
In order to justify payment for enteral nutrition, suppliers have met the following documentation in their records (to be available upon request):
- Standard Written Order (SWO)
- Medical record documentation (including continued need/use when applicable)
- Correct coding
- Proof of delivery (POD)
No more than one month's supply of nutrients, equipment or supplies is allowed with prospective billing. Claims submitted retroactively may include multiple months.
Treating Practitioner Expectations
A SWO is required for each item billed to Medicare. The medical records must support the information provided on the SWO, as an order is not considered part of the medical record.
The medical record must contain sufficient information about the medical condition to substantiate that the applicable Medicare coverage criteria have been met. The documentation must support that the beneficiary has full or partial non-function or disease of the structures that normally permit food to reach the small bowel; or, disease that impairs digestion/absorption of an oral diet, directly or indirectly, by the small bowel, and that the condition is of long and indefinite duration.
This information must justify the type of enteral nutrient ordered, the number of calories ordered, how the nutrition is administered, justification when special formulas are used, and the frequency of feedings.
The medical records must include enough information to support that coverage criteria have been met, including, but not limited to:
- Beneficiary’s diagnosis (this alone does not support medical necessity)
- Duration of beneficiary’s condition
- Clinical course (worsening or improvement)
- Prognosis
- Nature and extent of functional limitations
- Other therapeutic interventions and results
- Previous experience with related items
- Any other pertinent information related to use of enteral nutrition
The Clinician Letter - Medical Records and Documentation Checklist are invaluable resources to ensure all necessary information is included. Refer to the Noridian Medicare Enteral Nutrition webpage for additional resources.
