Enteral Nutrition Billing: Navigating Medicare MAC & State-Specific Guidelines (Post-2022 Updates)

IMPORTANT DISCLAIMER REGARDING MEDICARE COVERAGE: Effective January 1, 2022, the national CMS National Coverage Determination (NCD) for Enteral and Parenteral Nutritional Therapy (NCD 180.2 and 180.3, previously NCD 242.x) was officially retired. Medicare coverage decisions for enteral nutrition are now made at the discretion of individual Medicare Administrative Contractors (MACs) through their Local Coverage Determinations (LCDs). This guide has been revised to reflect these critical changes. Providers must consult their specific MAC’s LCDs for current coverage requirements, as national guidelines no longer apply.

Medicare Enteral Nutrition: Understanding Post-NCD Retirement Policies

The landscape for Medicare Administrative Contractor (MAC) enteral nutrition coverage significantly shifted with the retirement of the national NCD for enteral and parenteral nutritional therapy on January 1, 2022. This change means that coverage for enteral nutrition for Medicare beneficiaries is no longer uniform across the U.S. and is instead determined by individual MACs under Section 1862(a)(1)(A) of the Social Security Act, which focuses on services that are “reasonable and necessary.” This is a key **CMS enteral nutrition policy change** that providers must understand.

How to Navigate Local Coverage Determinations (LCDs) for Tube Feeding

Providers must now consult their specific MAC’s Local Coverage Determinations (LCDs) for tube feeding and orally administered enteral formulas. These LCDs outline the medical necessity criteria, documentation requirements, prior authorization processes, and specific **HCPCS codes enteral feeding update** details relevant to their jurisdiction. To locate these essential documents, utilize the Medicare Coverage Database on the official CMS website. Searching by your MAC and specific service (e.g., “enteral nutrition”) will yield the most current information regarding **enteral formula coverage Medicare**.

Medical Necessity & Documentation for Medicare Enteral Nutrition

While the national NCD is retired, the principle of “reasonable and necessary” under 1862(a)(1)(A) of the Social Security Act remains central. MACs interpret **medical necessity** based on clinical criteria that may vary significantly. Typically, documentation must be recent (e.g., less than 30 days old) and include:

• Specific diagnosis/medical condition necessitating enteral nutrition.
• Duration of need for enteral nutrition.
• Amount of calories and/or specific nutrients needed per day.
• Current height and weight, and changes over time, to demonstrate nutritional compromise or improvement.
• For tube feeding, the medical reason why oral intake is inadequate or contraindicated.
• For specialized formulas, documentation detailing why the unique composition is medically required and cannot be met by standard formulas or food.

Prior authorization requirements and specific documentation details should always be verified with the relevant MAC’s LCD.

HCPCS Codes for Enteral Formula Coverage Medicare

For appropriate **HCPCS codes enteral feeding update**, products are classified and listed on the website for the **Medicare Pricing, Data Analysis and Coding (PDAC) contractor**. Providers should be aware that while the PDAC provides coding guidance, specific coverage determinations and quantity limits are now primarily driven by local MAC policies following the NCD retirement. It is critical to note that HCPCS codes are subject to frequent changes, and local verification with your MAC and current PDAC lists is essential.

The following HCPCS codes are commonly associated with enteral nutrition, but their coverage and authorization requirements are now determined by individual MACs:

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

State Medicaid (e.g., MDHHS) Enteral Nutrition: Guidelines & Billing

Enteral nutrition administered by tube or orally into the gastrointestinal tract is crucial for many beneficiaries. Unlike Medicare, state Medicaid programs, such as those governed by the **MDHHS Medical Supplier/DME/Prosthetics and Orthotics Fee Schedule**, maintain their own specific guidelines for coverage and billing. These state-level rules are distinct from Medicare policies and have not been affected by the retirement of the national CMS NCD, making them crucial for accurate billing.

MDHHS Enteral Nutrition (Administered Orally)

MDHHS Standards of Coverage for Oral Enteral Nutrition

Standards of Coverage for MDHHS (Michigan Department of Health and Human Services) may cover orally administered enteral nutrition for beneficiaries under the age of 21 when:

• A chronic medical condition exists resulting in nutritional deficiencies, and a three-month trial is required to prevent gastric tube placement; or
• Supplementation to a 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 a low percentage increase in growth pattern or trend directly related to the nutritional intake and associated diagnosis/medical condition.

For **CSHCS Program** coverage (Children’s Special Health Care Services), 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 under MDHHS rules:

• 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).

MDHHS Documentation for Orally Administered Enteral Nutrition

Documentation for MDHHS must typically 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.

MDHHS Prior Authorization (PA) Requirements for Orally Administered Enteral Nutrition

PA is required for all enteral formula for oral administration under MDHHS. The following HCPCS codes typically 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**.

MDHHS Enteral Nutrition (Administered by Tube)

MDHHS Standards of Coverage for Tube Feeding

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

MDHHS Documentation for Tube-Administered Enteral Nutrition

Documentation for MDHHS must typically 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.

MDHHS PA Requirements for Tube-Administered Enteral Nutrition

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 under MDHHS:

• 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 typically 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 Billing Procedures & Payment Rules

Billing for Enteral Formula: Units and Quantity Limits

When billing for enteral formula (administered orally or by tube), the appropriate formula HCPCS code should generally 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. For state Medicaid programs like MDHHS, reimbursement for a maximum quantity of up to 900 units for any combination of approved formula may apply.

For Medicare beneficiaries, however, payment for **enteral formula coverage Medicare** is now entirely subject to the specific **Medicare Administrative Contractor (MAC) enteral nutrition** policies. MACs will define their own quantity limits, unit calculations, and covered supplies. Providers must confirm these details directly with the relevant MAC’s LCDs before billing.

Providers should refer to the following chart for additional assistance (note: quantity limits and reimbursement rates are illustrative and subject to local policy verification):

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.