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Enteral and Parenteral Nutrition

Coverage

Documentation

Reviews/Audits

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

Tips

Topic Details
Accessories
  • More than three nasogastric tubes (B4081-B4083) or one gastrostomy/jejunostomy tube (B4087-B4088) every three months is rarely medically necessary and requires extensive documentation for approval
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
  • When multiple products are billed, submit a separate DIF for each line item with answer to questions 3A (HCPCS) and 4A (calories per day) corresponding to individual line item on claim
  • If coverage requirements for enteral nutrition are met, medically necessary nutrients, administration supplies and equipment are covered
  • It is possible for Medicare to have a DIF on file that contains different information than most current DIF in supplier records. This could result in payments that are not in amount expected by supplier.  It is imperative that suppliers keep current on DIF submission to properly reflect current provision of nutrition
Formula
  • Enteral formulas consisting of semi-synthetic intact protein/protein isolates (B4150 or B4152) are appropriate for majority of beneficiaries requiring enteral nutrition
  • For special enteral formulas (B4149, B4153-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
Kits
  • Feeding supply kits (B4034-B4036) are specific to 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/Enteral Nutrition (PEN ) Therapy Payment Categories
  • Parenteral/Enteral Pump Rental/Purchase, and Maintenance and Servicing
Pumps
  • If a pump (B9000-B9002) is ordered, there must be sufficient documentation in 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 pump is not documented, pump will be denied
  • The reasonable useful lifetime (RUL) is considered eight years for parenteral/enteral pumps. Replacement may be considered with appropriate documentation

 

Upgrades

Scenario Formula Listed on Detailed Written Order (DWO) Formula Listed on DIF
Physician Orders Specialty Formula Specialty Formula Standard Formula
Physician Orders Standard Formula Beneficiary Requesting Specialty Formula Standard Formula Standard Formula
Physician Orders Standard Formula Specialty Formula Requested for Convenience Standard Formula Standard Formula

 

Last Updated Wed, 04 May 2022 15:14:49 +0000

The below are topic specific articles which have been published to "Latest Updates" and sent out in Noridian emails within the past two years. Exclusions to this include time sensitive related announcements such as: Noridian and CMS educational events, Ask-the-Contractor Teleconferences and claims processing downtime.

paginationType noridian
Parenteral Nutrition - Documentation Requirements 09/08/2022
Enteral Nutrition - Oral Intake 09/07/2022
Eliminating Certificates of Medical Necessity & Durable Medical Equipment Information Forms - January 1, 2023 08/08/2022
Parenteral Nutrition Tutorials 07/14/2022
LCD Revisions Summary for March 10, 2022 03/10/2022
Enteral Nutrition - Correct Coding and Billing - Revised 12/16/2021
Parenteral Nutrition - Correct Coding and Billing - Revised 12/16/2021
Enteral Nutrition Documentation Checklist 09/29/2021
Now Available - Parenteral Nutrition Modifier Tool 09/22/2021
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
Parenteral Nutrition - Correct Coding and Billing 10/08/2020
Enteral Nutrition - Correct Coding and Billing 10/08/2020
Retirement of Parenteral Nutrition Local Coverage Determination (LCD) and Related Policy Article - Effective November 12, 2020 10/08/2020
Retirement of Enteral Nutrition Local Coverage Determination (LCD) and Related Policy Article - Effective November 12, 2020 10/08/2020