Medicare Guidelines
Written Order Must Include:
- Beneficiary’s name
- Description or name of nutrients to be administered
- Method of administration (syringe, gravity or pump)
- Must include equipment required to administer feed (pump/IV pole for pump feeds and IV pole for gravity feeds)
- Rate of Administration
- If pump fed, rate needs to be documented in mls/hr
- Length of need (# of months or 99 = lifetime)
- Treating physician’s signature, date, NPI and printed name
- Ordering physician must be PECOS certified
- Start date of the order (if different than signature date)
- Current height and weight of patient
- Signature and date must be hand written (stamps are not acceptable)
Medical Record Documentation Must Include:
- Patient requires tube feeding to maintain weight and strength commensurate with overall health status
- Adequate nutrition must not be possible by dietarty adjustments and/or oral supplements
- Patient has permanent (at least 3 months) impairment
- Non-function or disease of the structures that normally permit food to reach the small bowel
- Disease of the small bowel with impaired digestion and absorption o an oral diet, either of which requires tube feedings to provide sufficient nutrients to maintain weight and strength commensurate with the patient’s overall health status
- Nutrition is being provided via a tube into stomach or small intestine
Additional Information Regarding Medical Record Documentation:
- Dysphagia: If dysphagia is the primary reason for tube feeds, the documentation should clearly support the diagnosis of SEVERE dysphagia to warrant feeding tube placement, such as: physician clinical documentation supporting the patient’s deficits, dysphagia evaluation, dietary documentation of how the patient tolerates different textures of food, or nursing documentation that shows difficulty in eating, expressions of pain, choking, etc. (Noridian; 2010)
- Refusal to eat: Enteral nutrition is non-covered for patients with a functioning gastrointestinal tract whose need for enteral therapy is due to reasons such as anorexia or nausea associated with mood disorder, end-stage disease, etc. (Noridian; 2010)
- Justification for feeding pump: Gravity feeding is not satisfactory due to reflux and/or aspiration, or severe diarrhea, or administration rate less than 100 ml/hr, or
- Blood glucose fluctuations, or Circulatory overload, or GJ tube or J tube used for feedings
Justification for Special Nutrient Formulas:
Specialty formulas include diabetic, renal, pulmonary, high-protein and blendarized; all of which are considered non-standard formulas.
The following information is required for these types of formula:
- Physician ordered special nutrient
- Medical record adequately documents specific medical condition and the need for the special nutrient
- A diagnosis alone does not qualify a patient for enteral nutrition. The physician needs to provide medical documentation to support the diagnosis (Noridian; 2010) Examples: blood sugar values, laboratory values, weight, documentation of intolerance, failure of other standard formulas, etc.
Justification for Daily Calories Prescribed:
According to Medicare standards, generally, daily intake of 750 to 2,000 calories is considered sufficient to maintain body weight. Patients receiving less than 750 or more than 2,000 calories per day must have documentation from their physician to explain why.
Items Not Covered Under Medicare:
- Enteral formula administered orally
- Feeding tubes and supplies when patient uses own home blendarized formula
- Feeding tubes and supplies used for hydration and/or medication administration
- Extension sets for low profile buttons
ABN:
If the patient doesn’t meet Medicare guidelines per the above information and makes the decision to accept services, Medicare requires that an Advanced Beneficiary Notice (ABN) is signed and kept on file.
- Upon signing this form, the patient acknowledges that Medicare is not expected to pay and if not covered, they will be financially responsible
- The ABN is also required to bill a secondary insurance (if applicable) for payment when it is non-covered by Medicare
