Enteral Nutrition Billing Guide

Enteral nutrition is nutrition administered by tube or orally into the gastrointestinal tract. Enteral nutrition is classified into categories that possess similar characteristics. Categories for enteral nutrition are listed by HCPCS codes on the MDHHS Medical Supplier/DME/Prosthetics and Orthotics Fee Schedule on the MDHHS website. For the appropriate HCPCS code, products are listed on the enteral nutrition product classification list on the website for the Medicare Pricing, Data Analysis and Coding (PDAC) contractor. If the formula is not listed in the covered HCPCS codes, the provider must contact the PDAC contractor for a coding determination. (Refer to the Directory Appendix for website and contact information.)

ENTERAL NUTRITION (ADMINISTERED ORALLY)

Standards of Coverage

Enteral nutrition (administered orally) may be covered for beneficiaries under the age of 21 when:

* A chronic medical condition exists resulting in nutritional deficiencies, and a threemonth trial is required to prevent gastric tube placement; or

* Supplementation to regular diet or meal replacement is required, and the beneficiary’s weight-to-height ratio has fallen below the fifth percentile on standard growth grids; or

* Physician documentation details low percentage increase in growth pattern or trend directly related to the nutritional intake and associated diagnosis/medical condition.

For CSHCS coverage, a nutritionist or appropriate pediatric subspecialist must indicate that long-term enteral supplementation is required to eliminate serious impact on growth and development.

For Healthcare Common Procedure Coding System (HCPCS) code B4162, the beneficiary must have a specified inherited disease of metabolism identified by the International Classification of Diseases (ICD).

For beneficiaries age 21 and over:

* The beneficiary must have a medical condition that requires the unique composition of the formula nutrients that the beneficiary is unable to obtain from food; or

* The nutritional composition of the formula represents an integral part of treatment of the specified diagnosis/medical condition; or

* The beneficiary has experienced significant weight loss. For Healthcare Common Procedure Coding System (HCPCS) code B4157, the beneficiary must have a specified inherited disease of metabolism identified by the International Classification of Diseases (ICD).

Documentation Documentation must be less than 30 days old and include:

* Specific diagnosis/medical condition related to the beneficiary’s inability to take or eat food.

* Duration of need.

* Amount of calories needed per day.

* Current height and weight, as well as change over time. (For beneficiaries under 21, weight-to-height ratio.)

* Specific prescription identifying levels of individual nutrient(s) that is required in increased or restricted amounts.

* List of economic alternatives that have been tried.

For continued use beyond 3-6 months, the CSHCS Program requires a report from a nutritionist or appropriate pediatric subspecialist.

PA Requirements PA is required for all enteral formula for oral administration.

The following HCPCS codes require authorization via a telephone authorization process:

B4034 B4035 B4036 B4081 B4082 B4083 B4087 B4088 B4102 B4149 B4150 B4152 B4153 B4154 B4155 B4157 B4158 B4159 B4160 B4161 B4162 B9000 B9002 B9998

Refer to the Directory Appendix for Telephone Prior Authorization Contractor information.

ENTERAL NUTRITION (ADMINISTERED BY TUBE)

Standards of Coverage

Enteral formula are covered when the diagnosis/medical condition requires placement of a gastric tube and nutrition is administered by syringe, gravity, or pump.

Documentation Documentation must be less than 30 days old and include:

* Specific diagnosis/medical condition requiring tube feeding.

* Duration of treatment.

* Amount needed per day.

* If a pump is required, the medical reason why syringe or gravity method could not be used.

PA Requirements PA is not required for standard formula for enteral tube feedings provided up to the program’s established quantity limits per month. (Applies only to specific enteral formula and related supplies and equipment. Refer to the Medicaid Code and Rate Reference tool for additional information.)

PA is required for the following:

* All specialized enteral formula requests for tube feedings.

* Over-quantity requests for standard formula enteral tube feedings.

* Medical need beyond Standards of Coverage.

The following HCPCS codes require authorization via a telephone authorization process:

B4034 B4035 B4036 B4081 B4082 B4083 B4087 B4088 B4102 B4149 B4150 B4152 B4153 B4154 B4155 B4157 B4158 B4159 B4160 B4161 B4162 B9000 B9002 B9998

Refer to the Directory Appendix for Telephone Prior Authorization Contractor information.

ENTERAL NUTRITION PAYMENT RULES

When billing for enteral formula (administered orally or by tube), the appropriate formula HCPCS code should be billed on a monthly basis with total calories used (divided by 100) as the unit amount. (To calculate the appropriate number of caloric units, combine total calories of all cans to be used and divide by 100.) Medicaid will reimburse for a maximum quantity of up to 900 units for any combination of approved formula.

Providers should refer to the following chart for additional assistance:

Formula 100 calories = 1 unit (u) 6 (8 oz) cans a day

1 month = 30 days

6 months = 180 days

5.00 cost/8 oz liquid or packet or can Standard @ 250 calories/8 oz 250 cals/100 =2.5 units 2.5 u x 6 = 15 units a day
15 u x 30 = 450 units a month 15 u x 180=2700 units for 6 months $5.00 ÷ 2.5 u = $2.00 per unit Caloric Dense @ 355
calories/8 oz 355 cals/100 =3.55 units 3.55 u x 6= 21 units a day 21 u x 30 = 630 units a month 21 u x 180 =
3780 units for 6 months $5.00 ÷ 3.55 u = $1.41 per unit Powder, 1 package = 150 calories 150 cals/ 100
= 1.5 units 1.5 u x 6 = 9  nits a day 9 u x 30 = 270 units a month 9 u x 180 =1620 units for 6 months $5.00 ÷ 1.5 u =
$3.33 per unit Powder, 1# can = 112 oz when mixed @ 20 calories/oz* = 2240 calories for the entire can

(*can vary with physician orders) 2240 cals/100 = 22.4 units 6 cans per month = 22.4 u x 6 = 134 units a month 134 u x 6 months = 804 units for 6 months $5.00 ÷ 22.4 u = $0.30 per unit

The necessary equipment and supply code for enteral tube feedings should be billed up to specified quantity limits. Feeding bags, anchoring devices, syringes, drain sponges, cotton tip applicators, tape, adaptors, and connectors used in conjunction with a gastrostomy or enterostomy tube are included in the supply kit codes and should not be billed separately.

Dietary formula for oral feedings may be obtained from either a medical supplier or a pharmacy.

Dietary formula for tube feedings are covered only through the medical supplier.