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January, 2007

Today's CPE: Medicare Reimbursement

of Home Nutrition Support

By Mike Nelson, RD, CNSD

Today’s Dietitian

Vol. 9 No. 1 P. 12

Learning Codes: 4080, 5000, 5220, 5440; CDR Level 2

In 1965, when Medicare was established as Title XVIII of the Social Security Act, nutrition support was virtually unknown and rules for the care of older adults, those with permanent disabilities, and patients with end-stage renal disease were simple. Today, both enteral and parenteral nutrition are included in the prosthetic device benefit provision of Part B of Medicare, which covers items that replace an organ or perform the function of a permanently inoperative or malfunctioning organ. The benefit covers supplies, equipment, and nutrients. (Medicare defines permanent as more than 90 days.)

Because the number of older adults covered by the benefit is likely to grow over the coming decades and because home care is becoming an increasingly attractive and necessary option for their care, home nutrition support will become even more important than at present. Dietitians can play a vital role in ensuring good care decisions—provided they understand the regulations and procedures, which are always evolving. This article will introduce dietitians to Medicare terminology, guidelines, and issues surrounding the utilization of home parenteral and enteral nutrition (PEN).

Medicare Part B is an optional program, and reimbursement for PEN support involves procedures and commitments from both beneficiaries and suppliers. The beneficiary needs to sign up for Part B to obtain coverage; the supplier will need to understand Medicare’s reimbursement system to follow its procedures. Criteria for reimbursement are fairly strict, and some home patients who could benefit from PEN may not be covered. For example, a patient may need parenteral nutrition for only 60 days, therefore not meeting the Medicare condition of permanence.

Dietitians have opportunities to help suppliers understand and improve compliance with the rules for reimbursement PEN therapies. Of first importance is communication. The Medicare system uses terminology and acronyms that dietitians may not recognize. In the following paragraphs, we’ll work through some of this bureaucratic alphabet soup—especially important since a new form is required beginning this month.

• Durable Medical Equipment Medicare Administrative Contractors (DME MAC) — Patients with Medicare are assigned to one of four DME MAC, based on the beneficiary’s address. For example, a beneficiary who lives in Iowa is in jurisdiction D and Noridian Administrative Services handles their claims. The Centers for Medicare & Medicaid Services (CMS) contracts with the DME MAC for processing Medicare claims for durable medical equipment, orthotics, and prosthetics (which includes PEN supplies, equipment, and nutrients). DME MAC, their Web sites, and the states they cover are listed in Table 1.

• Statistical Analysis Durable Medical Equipment Regional Contractors (SADMERC) — Medicare also contracts for a SADMERC to assist the CMS as a resource for suppliers in determining appropriate Healthcare Common Procedure Coding System (HCPCS) Level II codes when submitting claims to Medicare. The HCPCS code identifies the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) being billed. The current SADMERC contractor is Palmetto GBA. (See their Web site for the complete DMEPOS Fee Schedule: .) Tables 2 and 3 list some common PEN items and their HCPCS and DMEPOS Fee Schedule.

The HCPCS is a standardized coding system. PEN codes, maintained by the CMS, are alpha-numeric, consisting of a single alphabetical letter followed by four numeric digits. For example, B4150 is the HCPCS code for enteral formula, nutritionally complete with intact nutrients, including protein, fats, carbohydrates, vitamins and minerals, and possibly fiber. B4150 products are administered through an enteral feeding tube with 100 kilocalories equalling 1 unit. A common enteral product classified as B4150 is Nutren 1.0. See Tables 3 and 4 for a list of common HCPCS codes for enteral and parenteral products.

In addition, the SADMERC assists the CMS with the DMEPOS Fee Schedules and analyzes DMEPOS fees to identify unreasonable or excessive reimbursement amounts. Payment on a fee schedule basis is required for PEN—fees are updated annually. For example, the fee increased by approximately 2.6% in 2006.

The fee schedules list includes allowables or the amount of money Medicare would pay for a product if Medicare paid 100%. However, Medicare was designed to pay for 80% of the allowables. If a beneficiary has Medicare Supplement Insurance coverage, the insurance supplement will pay for the 20% not covered by Medicare. For example, a supplier bills for 180 cans of Nutren 1.0 (250 kilocalories per can) for one month of feeding. One hundred eighty cans of Nutren have 45,000 kilocalories, or 450 units. The Medicare allowable for 450 units is $301.50 ($0.67 per unit); thus, Medicare will pay 80% of $301.50, or $241.20.

The SADMERC also provides services to manufacturers to help them categorize their products. For example, if a manufacturer creates a new enteral product, the manufacturer will contact the SADMERC to categorize and assign an HCPCS number and fee.

• DME Information Form (DIF) — To receive Medicare reimbursement for PEN, a supplier will need to complete a DIF and send to its DME MAC. The DIF is a form required to help document the medical necessity of PEN therapy. This form replaced separate Certificate of Medical Necessary (CMN) forms for PEN, which had been used for this purpose, on January 1. Only DIF forms will be accepted by the DME MAC and will be available from the DME MAC.

The most significant change from CMN to DIF is that the supplier can now complete and sign the DIF, which should speed up the claims process for suppliers. In the past, a portion of the CMN needed to be completed and signed by the physician, which could lead to many delays in obtaining reimbursement for the supplier. Many times it was a struggle for the supplier to get the completed CMN back from the physician in a timely manner. Other times the information would be incorrect and would need to be sent back for correction. Making it even more difficult, Medicare regulations forbid the suppliers from assisting the physician in completing the CMN.

The DIF form requires some basic information such as the patient’s name, address, phone number, Medicare number, date of birth, gender, height, and weight. The supplier’s name, address, phone number, and Medicare supplier number, and the physician’s name, address, phone number, and physician identification. The DIF form also requires certain code numbers are also required. The proper diagnosis code (International Classification of Diseases, Ninth Revision [ICD-9]) needs to be documented to justify PEN therapy. (Coverage issues for PEN will be discussed later in this article.) See Tables 5 and 6 for some common ICD-9 codes for PEN.

In addition, the correct HCPCS codes for products delivered to the patient need to be added to the DIF. Refer to Tables 2 and 3 for some common HCPCS codes for PEN. Also, the correct code number for the place of service needs to be included on the DIF. The most common number is “12,” which identifies the patient’s home. (Using the code number “31,” identifying a skilled nursing facility, will result in the claim being denied since those facilities get reimbursement from other Medicare sources other than Part B.)

The estimated length of service needs to be recorded on the DIF. This number represents the number of months the patient is anticipated to be on the therapy unless the patient is expected to remain on PEN for life, in which case the number “99” is used. Many enteral patients with significant dysphagia have an estimated lifetime code. If the number of months is less than three, the claim will be denied since it does not meet the condition of permanence.

There are specific enteral and parenteral questions on the DIF. To obtain reimbursement for enteral therapy, questions 1 through 6 must be answered; for parenteral therapy, questions 6 through 9 need to be completed.

• Enteral question 1 requires documentation that the patient has a permanent inability to permit food to reach or be absorbed from the small intestine. Medicare considers the test of permanence to be three months or more or at least the anticipation of three months or more of therapy.

• Enteral question 2 requires the supplier to document that the patient is receiving the product via tube. Nutrition products taken orally are not covered by Medicare.

• Enteral questions 3 and 4 require the product’s HCPCS code and the number of calories per day from that product. For example, Nutren 1.0 is HCPCS code B4150. For six cans per day of Nutren 1.0, the patient would receive 1,500 kilocalories daily. See Table 4 for common HCPCS enteral codes.

• Enteral question 5 asks for the method of administration (eg, syringe, gravity, pump, or oral routes). Medicare will not cover enteral nutrition in which the method of administration is oral, and the method of administration must correspond to the supply kit being used. For example, if a supplier circles “pump” as the method of administration but gives the HCPCS code for gravity feeds, the DME MAC will either defer processing the claim to require a correction or reimburse at the lowest rate, which would be that for syringe-fed supplies.

• Question 6 must be answered for both enteral and parenteral therapy. The question asks how many days per week the therapy is being administered or infused. If a supplier answers something other than seven days per week, the claim may be denied or delayed for Medicare to determine why the patient is not receiving therapy every day.

• Parenteral question 7 wants the supplier to document that the patient has a permanent (90 days or longer) disease of the gastrointestinal (GI) tract that causes malabsorption severe enough to prevent the patient from maintaining weight and strength. If the patient does not have a long-term problem with intestinal digestion or absorption, Medicare will not cover parenteral nutrition. (Parenteral nutrition coverage is discussed in more depth later in the article.)

• Parenteral question 8 requires the supplier to document the parenteral prescription for amino acids, dextrose, and lipids. Medicare reimburses parenteral nutrition as a two-in-one solution, separating claims for the amino acids, dextrose, electrolytes, vitamins, and trace elements solution from those for lipids. The DME MAC will question and probably ask for additional justification for amino acids outside the range of 0.8 to 1.5 grams per kilogram per day or dextrose amounts less than 10%. The maximum amount of lipids Medicare will normally cover is 50 grams per day.

• Parenteral question 9 asks the supplier to document the access line for the parenteral nutrition administration. The choices are central line (including peripherally inserted central catheters), hemodialysis access, and peritoneal catheter. The most common access line choice is the central line.

The supplier then needs to sign and date the DIF, indicating that all the information on the form is accurate. Medicare can audit charts for medical justification for PEN therapy and can charge suppliers with fraud if the information in the medical record doesn’t justify the therapy and reimbursement.

Dietitians have an opportunity to widen their job responsibilities and become valuable team members in the reimbursement process by helping claim processors correctly fill out the clinical portions of the DIF. This can help justify the dietitian’s expense to the supplier by ensuring DIF accuracy, which results in a quicker reimbursement cycle for the supplier with a more efficient billing system.

As noted, Medicare Part B patients need to meet certain criteria prior to qualifying for coverage of their enteral feeding, equipment, and supplies: a permanent dysfunction that inhibits food reaching the small intestines or a small bowel disease that impairs digestion or absorption of an oral diet. (For example, dysphagia from esophageal cancer will not permit food to reach the intestines.) The enteral product needs to be delivered via tube; oral products are not covered by Medicare. (So if a patient is drinking Ensure—not receiving it via tube—the product, equipment, and supplies are not covered).

In addition, tube feedings need to provide sufficient nutrients to maintain weight and strength commensurate with the patient’s overall health status. Adequate nutrition must not be possible by dietary adjustments and/or oral supplements.

If the preceding requirements are met, Medicare will cover medically necessary nutrients, administration supplies, and equipment (eg, tubes, syringes, and dressings). However, coverage is possible for patients with partial impairment who can eat small amounts of food but need tube feedings to maintain their weight and nutritional status—for example, a patient with Crohn’s disease who is able to eat some food but needs prolonged tube feeding to overcome his or her problem with absorption.

Some common situations that are not covered by Medicare are patients who need enteral nutrition due to anorexia, nausea, or an end-stage disease but have a functioning GI tract and no obstruction or malabsorption problems.

Enteral

Formula Coverage

Once the patient meets Medicare enteral criteria, his or her formula will be covered. Formulas are classified (by composition) in the Product Classification List (PCL) published by the SADMERC. To bill Medicare, the supplier will need to use the PCL to correctly code the claim. Although most Medicare patients are over the age of 65, the list does classify pediatric formulas. Please consult the Web page for the complete listing of enteral formulas: . (See Table 4 for common product classifications.)

Medicare considers the enteral formulas in the B4150 or B4152 groups appropriate for the majority of patients requiring enteral nutrition and needs no additional medical justification; most tube feeding products utilized for home enteral patients will be classified within these two categories. However, Medicare requires additional medical justification for the other common classifications: B4149, B4153, B4154, and B4155.

For example, the use of a diabetic formula such as Glucerna (B4154) will need additional justification. The patient will need to try a B4150 formula first. If it results in an inability to control the patient’s blood glucose levels, the need for improved blood glucose control will justify Glucerna.

If medical justification for B4149, B4153, B4154, and B4255 formulas are not substantiated, the payment to the supplier will be based on the allowance for the least costly B4150 formula. This can cause a reimbursement problem since most formulas that need additional justification cost more than the B4150 allowable fee amounts. See Table 3 for the fee schedules for the various enteral formulas.

Method of Administration

Medicare will pay for “supply kits” to administer enteral formulas. There are three supply kits: syringe fed, gravity fed, and pump fed. Typical supplies include bags, tubing, syringes, dressing, and tape. Items may differ from patient to patient and day to day.

Typical patients will use a 60-milliliter syringe to feed themselves, since this is the quickest and easiest method of administration. However, if the patient is unable to tolerate the high rate of feeding from a syringe, he or she can try gravity feeds. (The gravity feeding rates can be slowed with a roller clamp on the tubing of the bag.) In that case, a supplier would deliver 30 gravity bags, four 60-milliliter syringes for water flushes, one tube adapter, and a roll of tape each month.

If the patient is unable to tolerate gravity feeding, an enteral pump can be utilized. The use of an enteral pump at home will require additional justification for reimbursement. Examples of medical justification where gravity feeding is not satisfactory include reflux and/or aspiration, severe diarrhea, dumping syndrome, a need for a pump rate less than 100 milliliters per hour, blood glucose fluctuations, circulatory overload, or need for a jejunostomy tube.

The patient has the option of having the enteral pump purchased by Medicare or rented by the month. It is unusual for patients to choose the purchase option since it would be the patient’s fiscal responsibility for maintenance and servicing of the pump—usually a patient rents the pump.

Medicare caps the number of months for renting pumps at 15. After 15 months, the supplier is still responsible for ensuring that the patient has a pump for the duration of medical necessity and maintaining and servicing the pump during duration of the therapy.

Medicare reimburses separately for IV poles and enteral tubes. If an IV pole is needed for gravity feeding or a pump, Medicare will either purchase or rent the pole. Medicare reimburses for one gastrostomy or jejunostomy tube every three months.

Parenteral

Nutrition Coverage

Medicare covers parenteral nutrition for patients with permanent, severe pathology of the alimentary tract, which does not permit absorption of sufficient nutrients to maintain weight and strength commensurate with the patient’s general condition.

A parenteral nutrition permanent impairment test is met if the patient is anticipated to be receiving parenteral nutrition for 90 days or more. If the patient is on parenteral nutrition for less than 90 days but was anticipated to be on longer at the initiation of the therapy, Medicare should still cover the claim.

The patient must have a condition involving the small intestine (and/or its exocrine glands) that impairs absorption of nutrients and/or a motility disorder that impairs the ability of nutrients to be transported through the GI tract. For example, short bowel syndrome impairs absorption of nutrients and would qualify.

Medicare covers parenteral nutrition as a last resort at maintaining a patient’s nutritional status. It must not be possible to maintain a patient’s weight and strength by modifying the nutrient composition of the diet—oral or enteral—or utilizing pharmacologic means to treat the etiology of the malabsorption problem (eg, pancreatic enzymes).

It is possible for parenteral nutrition to be covered for a patient who obtains partial nutrition from either the oral or enteral route. The specific criteria are spelled out later in this article.

Medicare considers the caloric range of 20 to 35 kilocalories per kilogram per day as sufficient to achieve or maintain weight. Caloric amounts other than 20 to 35 kilocalories per kilogram per day will need to be justified and documented in the medical record. For example, if an underweight patient is unable to gain weight with 35 kilocalories per kilogram per day, a parenteral nutrition solution can be increased to 40 kilocalories per kilogram per day.

Amino acid amounts outside the range of 0.8 to 1.5 grams per kilogram per day must be justified and documented in the medical record. For example, the serum albumin of a patient with pancreatitis continues to decline with 1.5 grams per kilogram per day, requiring the parenteral nutrition’s amino acid concentration to be increased to 2 grams per kilogram per day to improve his or her serum albumin level.

Any dextrose concentration less than 10% will need to be justified and documented in the medical record. Medicare considers dextrose concentrations less than 10% only partial parenteral nutrition and not enough nutrition to maintain weight and strength.

Medicare covers 50 grams per day of lipids or less with parenteral nutrition; 50 grams of lipids is 166 milliliters of 30% lipids, 250 milliliters of 20% lipids, or 500 milliliters of 10% lipids. The number of milliliters of lipids being used per day is important because the DIF requires documentation of the lipid percentage and the number of milliliters. If a supplier is utilizing more than 50 grams per day, Medicare may not reimburse a claim for more than 50 grams and the supplier will need to account for this decrease in reimbursement, making adjustments if necessary.

Specific Coverage

Along with general criteria a patient needs to meet to qualify for Medicare coverage for parenteral nutrition, the patient will need to meet specific conditions.

Medicare’s specific criteria for coverage of parenteral nutrition is divided into seven sections: A through G/H. Medicare requires a patient to meet these specific situations to qualify for parenteral nutrition. All situations will require documentation in the medical chart justifying the claim.

• Situation A is for a patient who has had a small bowel resection and has less than 5 feet (152 centimeters) of small bowel left beyond the ligament of Treitz. The surgery needs to have occurred within the previous three months. Many times surgeons will not document the amount of small bowel left after a small bowel resection, making it difficult to justify a patient’s therapy under this Medicare situation. If possible, try to ask that this length be documented.

• Situation B is for a patient with short bowel syndrome diagnosis who has lost more than 50% of his or her oral or enteral intake. The patient needs to have an oral intake of at least 2.5 to 3 liters per day and a urine output of less than 1 liter per day. A dietitian can assist a supplier by documenting the oral or enteral intake.

• Situation C is for a patient who requires bowel rest because of symptomatic pancreatitis, severe regional enteritis, or a proximal enterocutaneous fistula when a tube feeding distal of the fistula is not possible. This is a straightforward situation to document, requiring only the appropriate diagnosis and meeting general parenteral coverage requirements.

• Situation D is for a patient who has a complete mechanical small bowel obstruction where surgery is not an option. This is another medical condition that only requires a physician’s diagnosis determination.

• Situation E is for a patient who is malnourished from malabsorption. The patient must have had a 10% or greater weight loss in three months or less, with a serum albumin equal to or less than 3.4 grams per deciliter. The patient will also need fecal fat test results that show fecal fat of 50% of the oral/enteral intake or higher on a diet of 50 grams fat per day or more. Also, the patient will need a nutritional assessment by a physician, dietitian, or other qualified professional completed within one week prior to the initiation of the parenteral nutrition. The dietitian can help the supplier by completing a nutrition assessment of the patient.

• Situation F is for a patient who is malnourished with chronic nausea and vomiting. The patient must have had a 10% or greater weight loss in three months or less, with a serum albumin of 3.4 grams per deciliter or less. The patient also needs to be on maximum doses of prokinetic medication (eg, Reglan) and have daily symptoms of nausea and vomiting. The patient will also need an abnormal small bowel motility study. Additional documentation is more extensive than previous situations. Medicare requires a nutritional assessment from a qualified professional within one week prior to initiation of parenteral nutrition with:

- information on current weight and weight one to three months prior;

- estimated daily calorie intake during the prior month and a determination whether there were caloric losses from vomiting or diarrhea and whether these estimated losses are reflected in the calorie count; and

- a description of any dietary modifications made or supplements tried during the prior month (eg, low-fat diet with increased medium-chain triglyceride oil).

The dietitian is the most qualified professional to assess all the previous nutritional elements, and he or she will need to make sure to include all elements required by Medicare. (Otherwise, the supplier may not receive reimbursement.) This requires considerable effort—for example, the need to document the patient’s caloric intake the previous month prior to parenteral nutrition takes planning and a large amount of documentation and work.

• Situation G/H. This situation encompasses cases in which the patient needs parenteral nutrition but does not fit into any of the previous situational criteria. The documentation and criteria options are extensive. To qualify, the patient must meet the following conditions:

- at least 10% weight loss in less than three months;

- a serum albumin less than or equal to 3.4 grams per deciliter;

- altering the nutrient composition of an enteral diet will not maintain the patient’s health status; and

- the patient’s health status cannot be maintained by administering medications to treat the etiology of the malabsorption.

If all four criteria are met, the patient must then have one of the following moderate abnormalities:

• Seventy-two–hour fecal fat study showing that fecal fat is greater than 25% of oral/enteral intake on a diet with more than 50 grams of fat per day;

• a diagnosis of malabsorption with objective confirmation by methods other than 72-hour fecal fat test (eg, Sudan stain of stool, d-xylose);

• gastroparesis demonstrated by study that shows the isotope, barium, or pellets failed to reach the right colon in three to six hours or a manometric motility study consistent with abnormal gastric emptying unresponsive to prokinetic medication;

• small bowel motility disturbance unresponsive to prokinetic medication demonstrated with a gastric to right colon transit time between three and six hours;

• small bowel resection that left more than 5 feet of small bowel beyond the ligament of Treitz;

• short bowel syndrome not as severe as Situation B;

• mild to moderate exacerbation of regional enteritis or enterocutaneous fistula; or

• partial mechanical small bowel obstruction, where surgery is not an option.

If the criteria are met, the medical record must document a failed tube trial.

Dietitians have an opportunity to expand their practice by assisting suppliers of home PEN in improving their Medicare reimbursement. They should begin now, with the introduction of new paperwork, to advise and inform medical and administrative staff of their role. The system is complicated, but it can be decyphered and systems can be set up to make it work.

— Mike Nelson, RD, CNSD, is the clinical nutrition manager at Mercy Medical Center Redding in California. He coordinates nutrition support activities at this Level III Neonatal Intensive Care Unit and Level II Trauma Center Hospital. He has worked in home infusion and home health since 1988.

Resources

AdminaStar Federal, Inc.,

Centers for Medicare & Medicaid Services,

Cigna,

National Heritage Insurance Company, dme/index.shtml

Noridian Administrative Services, LLC,

Ireton-Jones C, DeLegge M. Home parenteral nutrition registry: A five-year retrospective evaluation of outcomes of patients receiving home parenteral nutrition support. Nutrition. 2005:21(2):156-160.

Wojtylak F. Medicare enteral and parenteral reimbursement: Requirements for successful coverage and payment. Support Line. 2006;18(4):18-23.

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