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Enteral & 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
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

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 Apr 27, 2018

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.

Policy Specific Requirements for Enteral Nutrition Detailed Written Orders  May 12, 2017
Enteral Nutrition (HCPCS B4150, B4154) Notification of Service Specific Prepayment Probe Review  Dec 19, 2016
Enteral Nutrition (HCPCS B4035) Notification of Service Specific Prepayment Targeted Review  Jul 06, 2016