Medicare covers enteral nutrition (EN) under the prosthetic device benefit when coverage, documentation, and payment requirements are met. Coverage criteria and documentation requirements are outlined in the Enteral Nutrition Local Coverage Determination (LCD L38955) and the related Policy Article (A58833). Claims that do not meet these requirements are subject to denial.

Enteral nutrition continues to be a focus area for the Comprehensive Error Rate Testing (CERT) program. Recent CMS compliance updates show a high improper payment rate for enteral nutrition, with documentation deficiencies identified as the leading cause of errors.

According to CMS CERT reporting, insufficient documentation accounts for the largest portion of improper payments for enteral nutrition claims. Other contributing factors include lack of medical necessity and failure to meet policy requirements.

CERT reviews identified the following common errors:

• Failure to demonstrate that the beneficiary initially met coverage criteria
• Missing or insufficient documentation to support continued medical need
• Incomplete or invalid Standard Written Orders (SWOs)
• Lack of documentation supporting the medical necessity of an enteral pump
• Medical records that do not support the type of formula, calories ordered, or method of administration

During a CERT review, claims are evaluated on the documentation submitted. If required documentation is missing, unclear, or does not support coverage criteria, the claim is considered non‑payable.

Suppliers are responsible for ensuring that all required documentation is obtained, reviewed, and maintained prior to claim submission. Documentation must support each element required for coverage and payment, including:

• A permanent or long‑term condition resulting in full or partial non‑function of the digestive tract
• Documentation supporting adequate nutrition is not possible by oral intake
• Medical records supporting medical necessity and continued need for enteral nutrition
• A valid and complete Standard Written Order (SWO)
• Compliant refill request documentation
• Proof of delivery (POD) documentation

Medical records must clearly support the information reflected on the SWO. Orders alone are not sufficient on their own to establish medical necessity. Failure to meet requirements may result in claim denial, overpayments, or additional medical review. Use the Enteral Nutrition Documentation Checklist to ensure documentation requirements are met.