Enteral and Parenteral Nutrition

Coverage and Documentation

Reviews/Audits

  • Medical Review - View notifications/findings of pre/post claim reviews completed by Noridian Medical Review

Enteral Nutrition

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

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.

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.

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
Last Updated Aug 22 , 2024

Related Articles

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Articles Source Posted
Targeted Probe and Education (TPE) Pre-Payment Reviews 10/15/2024
Medical Documentation: A Reminder for Enteral and Parenteral Nutrition 10/09/2024
Enteral and Parenteral Modifiers - Proper Use 07/24/2024
Targeted Probe and Education (TPE) Pre-Payment Reviews 04/24/2024
Enteral Nutrition DME on Demands 04/03/2024
Enteral and Parenteral Nutrition Refill Requirements 03/06/2024
LCD and Policy Article Revisions Summary for December 14, 2023 12/14/2023
LCD and Policy Article Revisions Summary for November 9, 2023 11/09/2023
Enteral Nutrition - Documentation Requirements 11/08/2023
Enteral Nutrition Targeted Probe and Educate Webpage 08/16/2023
Enteral Nutrition, Osteogenesis Stimulators, Parenteral Nutrition and Seat Lift Mechanisms - Final LCDs and Response to Comments (RTC) Articles Published 05/18/2023
LCD and Policy Article Revisions Summary for May 18, 2023 05/18/2023
Enteral and Parenteral Prospective Use 04/13/2023
Noridian Enteral and Parenteral Nutrition Self-Paced Tutorials 10/19/2022
Parenteral Nutrition - Documentation Requirements 09/08/2022
Enteral Nutrition - Oral Intake 09/07/2022
LCD Revisions Summary for March 10, 2022 03/10/2022
Enteral Nutrition and Parenteral Nutrition - Final LCDs and Response to Comments (RTC) Articles Published 07/22/2021
Open Meeting Announcement - Oral Appliances for Obstructive Sleep Apnea, Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea, and Respiratory Assist Devices Proposed Local Coverage Determinations (LCDs) 02/25/2021
Open Meeting Announcement - Enteral Nutrition and Parenteral Nutrition Proposed Local Coverage Determinations (LCDs) 02/25/2021
Proposed Local Coverage Determinations (LCDs) Released for Comment - Enteral Nutrition, Oral Appliances for Obstructive Sleep Apnea, Parenteral Nutrition, Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea, and Respiratory Assist Devices 02/25/2021
Now Available-Parenteral Nutrition Modifier Tool 02/24/2021