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Enteral & Parenteral Nutrition

Coverage

Documentation

Document Type Description
CMS 10126 DIF [PDF] Enteral/Parenteral Nutrition DME Information Form (DIF)
Enteral Documentation Checklist [PDF] Suppliers may use these checklists to ensure all required documentation is gathered
Parenteral Nutrition Documentation Checklist [PDF]
Physician Letter - CERT Enteral Nutrition [PDF] This letter to physicians is specifically regarding documentation of enteral nutrition
Physician Letter - Medical Records [PDF] This letter may be sent to physicians to assist in obtaining documentation

 

Reviews/Audits

Review Type Description
Medical Review View notifications and findings of pre and post claim reviews completed by Noridian Medical Review Staff

 

Reminders

Topic Reminder
Accessories More than three nasogastric tubes (B4081-B4083) or one gastrostomy/jejunostomy tube (B4087-B4088) every three months is rarely medically necessary and would require extensive documentation for approval.
Billing

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.

When multiple products are billed, submit a separate DIF for each line item with the answer to questions 3A (HCPCS) and 4A (calories per day) corresponding to the individual line item on the claim.

If the 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 the most current DIF in the supplier records. This could result in payments that are not in the amount expected by the supplier.  It is imperative that suppliers keep current on DIF submission to properly reflect the current provision of nutrition.

Formula

Enteral formulas consisting of semi-synthetic intact protein/protein isolates (B4150 or B4152) are appropriate for the majority of beneficiaries requiring enteral nutrition.

For special enteral formulas (B4149, B4153-B4157, B4161, and B4162) the medical necessity will need to be justified for each beneficiary as to why this special formula is needed versus the semi-synthetic enteral formula.

Kits Feeding supply kits (B4034-B4036) are specific to the route of administration and the submission of a claim for more than one type of kit code delivered on the same date or provided on an ongoing basis will be denied as not medically necessary.
Pumps If a pump (B9000-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".
Note: If the medical necessity of the pump is not documented, the pump will be denied.


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 May 31, 2017

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