Article Detail - JD DME

Posted September 20, 2013

The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have identified a growing trend in Comprehensive Error Rate Testing (CERT) errors for Enteral Nutrition related items. Suppliers are reminded of §1833(e) of the Social Security Act which precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider." It is expected that the beneficiary's medical records will reflect the need for the care provided. The beneficiary's medical records may include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be made available upon request from any auditing Medicare contractor.

Detailed Written Orders:

The detailed written order (DWO) for enteral nutrition is required prior to claim submission. The Medicare program allows for someone other than the ordering physician to create/produce the DWO. However the ordering physician must review the content of the DWO and sign and date it. The DWO must contain the following elements:

• Beneficiary's name

• Physician's name

• Date of the order and the start date, if start date is different from the date of the order

• Detailed description of the item(s) (see below for specific requirements for selected items)

• Physician signature and signature date

For items provided on a periodic basis, including drugs, the written order must include:

• Item(s) to be dispensed

• Dosage or concentration, if applicable

• Route of Administration

• Frequency of use

• Duration of infusion, if applicable

• Quantity to be dispensed

• Number of refills

Failure to secure a DWO with the required elements indicated will render the order incomplete and result in an error and refund request.

Clinical Records Documentation:

Information contained directly in the contemporaneous medical record is the source required to justify payment except as noted elsewhere for prescriptions. Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves for the purpose of determining that an item is reasonable and necessary.

Enteral nutrition is covered for a beneficiary who has one of the following:

a) permanent non-function or disease of the structures that normally permit food to reach the small bowel or

b) disease of the small bowel which impairs digestion and absorption of an oral diet, either of which requires tube feedings to provide sufficient nutrients to maintain weight and strength commensurate with the beneficiary's overall health status.

When one of these two requirements is met, the Medicare program will reimburse for the nutrients, supply kits and the enteral nutrition pump when needed. The most common error relating to the clinical record documentation for enteral nutrition is the failure to show that the medical necessity is met as outlined in the medical policy. Suppliers are responsible for securing clinical record information that clearly documents the beneficiary's condition.

Nutrients

When the coverage criteria is met for the enteral nutrition therapy, the enteral formulas consisting of semi-synthetic intact protein/protein isolates (B4150 or B4152) are deemed appropriate for the majority of beneficiaries requiring enteral nutrition.

If the patient exhibits intolerance to any semi-synthetic formula, the medical record must reflect the unfavorable events that resulted in the prescribing of the special enteral formula (B4149, B4153-B4155, B4157, B4161, and B4162). If a special enteral nutrition formula is provided and if the medical record does not document why that item is medically necessary, it will be denied as not reasonable and necessary.

Continued Medical Need

In addition to establishing the initial need for enteral nutrition, the clinical records may also be used to support continued medical need. Use of the clinical record to support continued medical need for the nutrients, supplies and equipment must be timely. Per the LCD requirements for continued medical need, the clinical documentation must be within the preceding 12 months of the date of service under review. Suppliers are not limited to the clinical record to support continued medical need and may use any of the following documents, in lieu of the clinical record to support that the items remain reasonable and necessary.

• A recent order by the treating physician for refills

• A recent change in prescription

• A properly completed CMN or DIF with an appropriate length of need specified

Signature Requirements

These guidelines apply not only to claims reviewed by the durable medical equipment Medicare administrative contractor (DME MAC), but also to claims reviewed by the Comprehensive Error Rate Testing (CERT) contractor, program safeguard contractor (PSC), and recovery audit contractor (RAC). For medical review purposes, Medicare requires that all orders and medical records that are used in the adjudication of claims be authenticated by the author. The method used must be a legible handwritten full signature, handwritten initials, or electronic signature. Those requirements are published in the CMS Internet-Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3, §3.4.1.1

Durable Medical Equipment Information Form (DIF)

Enteral nutrition is an item that requires a DIF. A valid DIF is one in which the supplier has attested to and signed supporting the medical need for the item. When the DME MACs, DME PSCs, and ZPICs identify a claim for which a DIF is not valid, they may deny the claim and/or initiate overpayment action. Suppliers are required to complete the DIF including their signature prior to claim submission. If the DIF is used to verify that statutory benefit requirements have been met, then the claim will be denied as not meeting the benefit category. Therefore, it is imperative that suppliers complete the DIF accurately to ensure that claims are adjudicated appropriately. For complete details concerning the completion of the DIF form, please consult the CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 5, §5.3.

This article is only a summary of the Enteral Nutrition coverage and documentation requirements. Suppliers should read the entire Enteral Nutrition Local Coverage Determination and related Policy Article for additional coverage, coding and documentation requirements.