Enteral and 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, B4082, and B4083) or one gastrostomy/jejunostomy tube (B4087 or B4088) every three months is not medically necessary
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
  • If coverage requirements for enteral nutrition are met, medically necessary nutrients, administration supplies and equipment are covered
  • It is possible for Medicare to have records on file that contains different information than in supplier records. This could result in payments that are not in an amount expected by the supplier. It is imperative that suppliers keep current records on file to properly reflect current provision of nutrition. Denials must follow the appeals process
  • Enteral and Parenteral Prospective Use Billing
Formula
  • Enteral formulas consisting of semi-synthetic intact protein/protein isolates (B4150 or B4152) are appropriate for a majority of beneficiaries requiring enteral nutrition
  • For special enteral formulas (B4149, B4153-, B4154, B4155, 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
Supply Kit Fee/Allowance
  • The enteral feeding supply kit is a daily feeding supply fee/allowance, and includes all supplies, other than the feeding tube and nutrients, required for the administration of enteral nutrients to the beneficiary for one day. The supply needs will vary between beneficiaries.
  • Enteral feeding supply kit (B4034, B4035, and 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
  • Parenteral supply allowances (B4220, B4222 and B4224) allow only one supply kit and one administration kit for each day parenteral nutrition is administered. This a daily supply fee rather than a specifically defined "kit" and include all supplies required for the administration of parenteral nutrition to the beneficiary for one day
Parenteral/Enteral Nutrition (PEN) Therapy Payment Categories
  • Parenteral/Enteral Pump Rental/Purchase, and Maintenance and Servicing
Pumps
  • If an enteral pump (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
  • Only one infusion pump (B9004, B9006) is covered for beneficiaries in whom parenteral nutrition is required
  • The reasonable useful lifetime (RUL) is considered eight years for parenteral/enteral pumps. Replacement may be considered with appropriate documentation

 

Modifiers

Use Details
Nutrition/supplies
  • BA - Item(s) furnished in conjunction with parenteral enteral nutrition services (gravity or pump administered nutrition)
  • BO - orally administered enteral nutrition (non-covered)
Purchase option
  • BP - Beneficiary selected purchase option
    • Append to pump before month 10
    • Example: B9002NUKXBP
  • BR - Beneficiary selected rental option
    • Append to pump before month 10
    • B9004RRKHKXBR
  • BU - Beneficiary did not inform supplier of decision
Pump Modifiers
  • RR - Pump rental
  • NU - New pump purchase
  • UE - Purchase of used pump
  • KH - Initial claim, first month pump rental
  • KI - Second and third month pump rental
  • KJ - Rental months four to fifteen
Maintenance and Service
  • MS - Pump Maintenance and Service
    • Enteral: one-half rental payment may be paid every six months, six months after last rental month
    • Parenteral: one-half rental payment may be paid every three months, three months after last rental month
Policy Modifiers

Modifier Lookup Tool
  • EY - No physician or other healthcare provider order on file (not reasonable and necessary)
  • KX - All the coverage criteria in the "Coverage Indications, Limitations, and/or Medical Necessity" section in the related LCD have been met
    • Required for use on claims with date of service July 2, 2023 and after
  • GA - policy criteria is not met. Waiver of Liability statement on file. Valid Advance Beneficiary Notice of Noncoverage (ABN) obtained
    • Required for use on claims with date of service July 2, 2023 and after, if the KX modifier does not apply, and a valid ABN is received
  • GZ - item or service expected to be denied as not reasonable or necessary, no valid ABN on file. (Automatically denied/not subject to complex medical review)
    • Required for use on claims with date of service July 2, 2023 and after
    • KX, GA, GY modifiers do not apply
  • GY - Item or service statutorily excluded or does not meet the definition of any Medicare benefit
    • Required for use on claims with date of service July 2, 2023 and after
    • KX, GA, GZ modifiers do not apply
  • 99 - Modifier overflow- When more than four modifiers are required to describe a service on the same code, replace the fourth modifier with modifier 99

 

Last Updated Dec 09 , 2023

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