Durable Medical Equipment (DME) Information Form (DIF) for Parenteral Nutrition

The Parenteral Nutrition policy requires a DIF), form 10126. This form must be completed, signed, dated by the supplier, kept on file and made available upon request to the Medicare contractor (MAC). The initial claim must include an electronic copy of the DIF. All items being billed to Medicare must be on this form. In the case of upgrades, we ask that the DIF only include the item(s) the beneficiary qualifies for, not the upgraded item(s).

A new Initial DIF is required when:

  • Parenteral nutrition services are resumed when they are not required for two consecutive months.

A revised DIF is required when:

  • There is a change in HCPCS code for the current nutrient provided
  • There is a change (increase or decrease) in the calories prescribed for any HCPCS codes other than B4189, B4193, B4197, B4199, B5000, B5100, B5200
  • There is a change in the number of days per week of administration
  • There is a change in route of administration
  • The length of need (LON) previously entered on the DIF has expired and the treating practitioner is extending the LON for the item(s)

Note: When billing for more items than space allows on the DIF, suppliers may add these codes to question 3. The supply kits do not require a DIF but may also be listed in question 3 with overflow codes.

Reminder: The information on the DIF must be corroborated within the medical record and the Standard Written Order (SWO). If the medical record does not support parenteral nutrition requirements, question 7 must be answered "no". By answering no on question 7, the claim will deny as non-covered.

            Last Updated Fri, 13 May 2022 14:57:00 +0000