Enteral and Parenteral Prospective Use - JA DME
Enteral and Parenteral Prospective Use
For enteral and parenteral claims, no more than a 1-month quantity of nutrients, equipment, or supplies may be dispensed at one time.
- Maximum number of supplies that can be dispensed at one time is a 31-day supply.
Suppliers are expected to be aware of the beneficiary's utilization patterns, recognize atypical use or changes to utilization patterns, and only dispense what is medically necessary. Contact with the practitioner may be necessary to ensure that the changes in patterns of use are warranted.
- Picked up at retail location - Proof of refill for supplies may be an itemized receipt or the signed delivery slip.
- Delivered or Shipped - Suppliers must have contact with the beneficiary prior to dispensing refills.
- Refills may not be automatically dispensed without a request for refill from the beneficiary.
- The refill request may not take place sooner than 14 calendar days before their current supply is exhausted, and the supplier may not ship or deliver the products sooner than 10 days prior to the exhaustion of supplies or nutrients on hand.
- Refilled items must be reasonable and necessary.
- Detailed records should be kept to record contact between the supplier and beneficiary.
- If the beneficiary has not used all of their previously delivered nutrients or supplies, the supplier should either delay delivery of the next shipment or reduce the quantity delivered so there is no more than one month's supply on hand at any one time.
- This may occur in situations in which the beneficiary was admitted to the hospital, or in which the beneficiary did not receive their usual nutrient intake because of an acute illness, or similar circumstance.
- Refill requirements are not applicable to HCPCS codes:
- Enteral daily supply allowances - B4034, B4035, and B4036
- Parenteral nutrition supply allowances - B4220, B4222 and B4224
These codes are considered all-inclusive and include all supplies required for the administration of nutrition to the beneficiary for one day. Actual use of the supplies is expected to vary for each beneficiary. The unit of service (UOS) for the supply allowance is one (1) UOS per day (not to exceed 31 per month).
Reminder: There should not be reason to routinely bill the supply allowance 10 days earlier each month.
Providing Items to Beneficiary
The supplier may deliver the nutrition and supplies directly to the beneficiary or may use a shipping service to ship the items.
- Delivered by the supplier directly to the beneficiary:
- The "From" date of service (DOS) on the claim will be the actual date the items were received by the beneficiary.
- Shipped to the beneficiary via shipping service:
- The "From" DOS will be the date the items were shipped (the date the shipping label is created or the date the shipping service retrieves the items) or may be the date the items were delivered to the beneficiary. Either way, the supplier record must be linked to the shipping record by a clearly identifiable method.
- To determine the "To" DOS, the supplier counts the number of days the nutrients are expected to last (example, the supplier ships a 28-day supply) and adds that number of days to the "From" date on the claim. The span dates will not always match the dates of expected use for the nutrients.
Example one: Nutrition and supplies shipped via shipping service
- 02/01/2023: 28-day supply shipped
- 02/04/2023: Beneficiary receives supply of nutrients
- 02/05/2023: Beneficiary starts using nutrients
- 03/04/2023: Beneficiary finishes supply of nutrients in this shipment
DOS on the claim:
- "From" date = 02/01/2023 (date the nutrients were shipped)
- "To" date = 02/28/2023 (28 days after the "From" date since a 28-day supply was shipped)
Note: The span dates ("From" and "To" dates) are determined by the date the nutrients shipped and the number of days for which the quantity shipped is expected to last. The span dates do not necessarily coincide with the dates the beneficiary actually used the nutrients.
- 02/22/2023: Supplier calls beneficiary to determine usage during the previous month and determine quantity of next shipment
- 02/24/2023: 31-day supply of nutrients shipped to beneficiary (expected dates of use; 03/01/2023 - 03/31/2023)
- 02/28/2023: Beneficiary receives shipment
- 03/01/2023: Beneficiary begins using nutrients in this shipment
- 03/13/2023 - 03/20/2023: Beneficiary admitted to inpatient hospital stay
- 04/08/2023: Beneficiary exhausts supply
DOS on the claim:
- "From" date: 02/24/2023 (date the nutrients were shipped)
- "To" date: 03/26/2023 (31 days after the "From" date since a 31-day supply was shipped)
Note: The next month's shipment would be delayed to account for additional supplies on hand due to the inpatient hospital stay.
- Shipping Supply Kits
- Supply kits consist of multiple items which are sometimes shipped separately. As with nutrients, the span dates on the claim will not always match the dates of expected use of the supplies.
Example two: Shipped via shipping service
- 02/01/2023: 28-day supply of bags and tubing shipped
- 02/08/2023: 28-day supply of irrigation syringes shipped
- 02/26/2023: 28-day supply of bags and tubing shipped
Claim submission based upon above shipping example:
- HCPCS: B4035
- Units of service: 28 UOS
- From DOS: 02/01/2023
- To DOS: 02/28/2023
- HCPCS: B4035
- Units of service: 31 UOS (expected dates of use; 03/01/2023 - 03/31/2023)
- "From" DOS: 02/26/2023
- "To" DOS: 03/28/2023
Last Updated Thu, 21 Sep 2023 13:42:51 +0000