CODING, COVERAGE AND REIMBURSEMENT

This section currently focuses primarily on Medicare. It may be expanded in the future to include information on private insurers as well.

General

• Coverage of parenteral and enteral nutrition as a Part B benefit is provided under the Prosthetic Device benefit (Social Security Act § 1861(s)(8)) provision which requires that the patient must have a permanently inoperative internal body organ or function thereof. Therefore, enteral and parenteral NUTRITIONal therapy are normally not covered under Part B in situations involving temporary impairments. Documentation should state that impairment is permanent
• Medicare coverage of nutrition therapy services and enteral and parenteral nutrition therapy is managed by Medicare and Medicare Administrative Contractors (MAC) CGS Administrators, LLC and Noridian Healthcare Solutions, LLC. Coverage is explained by the:
• • National Coverage Determination (NCD): 180.2 Enteral and Parenteral Nutritional Therapy
  • National Coverage Determination (NCD): 180.1 Medical Nutrition Therapy (nutritionist services for diabetic and renal patients)
  • Local Coverage Determination (LCD): Parenteral Nutrition (L33798) https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33798&ContrID=140
  • Local Coverage Article: Parenteral Nutrition - Policy Article (A52515) https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52515&ContrID=140
  • Local Coverage Determination (LCD): Enteral Nutrition (L33783) https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33783&ContrID=140
  • Local Coverage Article: Enteral Nutrition - Policy Article (A52493) https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52493&ContrID=140

• Frequency limitations are calculated based on Medicare guidance for nutrient needs. Any exception needs to be justified and documented by the ordering physician 
• • A total caloric daily intake (parenteral, enteral and oral) of 20-35 cal/kg/day is considered sufficient to achieve or maintain appropriate body weight. 
  • protein orders in range of 0.8-1.5 gm/kg/day,
  • dextrose concentration of 10%
  • lipids less than 1500 grams per month. 
• The following items are covered by Medicare Part B when requirements are met:

Parenteral Nutrition Therapy

Parenteral Nutrient Solution - Separate nutritional components (to be mixed by beneficiary)

• HCPCS: 
• Coverage requirements: 
• Frequency limitations:  units of service needed per day   Nutrient solutions for parenteral therapy are routinely covered. However, Medicare pays for no more than one month’s supply of nutrients at any one time. 
• Non-covered conditions: 
• Billing reminders: 

Parenteral Nutrient Solution - Pre-mixed solution

• HCPCS:
• Coverage requirements:  the medical record, including a signed statement from the attending physician, establishes that the beneficiary, due to his/her physical or mental state, is unable to safely or effectively mix the solution and there is no family member or other person who can do so. Medical necessity for special parenteral formulas (B5000-B5200) must be justified in each beneficiary. 
• Frequency limitations:
• • For codes B4189-B4199, frequency limitation is 1 unit of service per day . 
  • For codes B5000-B5200: units of service needed per day  
  • B4185: 150 units of service per month 

• Non-covered conditions: 
• Billing reminders:
• • For codes B4189-B4199, one unit of service represents one day's supply of protein and carbohydrate regardless of the fluid volume and/or the number of bags. For example, if 60 grams of protein are administered per day in two bags of a premix solution each containing 30 grams of amino acids, correct coding is one (1) unit of B4193, not two units of B4189.
  • For codes B5000-B5200, one unit of service is one gram of amino acid. 
  • For B4150 ADD THE BO MODIFIER TO THE HCPCS CODE IF THE ENTERAL NUTRITION IS BEING ADMINISTERED ORALLY AND IS NOT BEING ADMINISTERED BY A FEEDING TUBE.Re-validated 10/17/2011

Parenteral Nutrition Infusion Pump and Supplies

• HCPCS:
• Coverage requirements:  it must be supported by sufficient medical documentation to establish that the pump is medically necessary, i.e., gravity feeding is not satisfactory due to aspiration, diarrhea, dumping syndrome.
• Frequency limitations:
• • Infusion pumps (B9004-B9006) are covered for beneficiaries in whom parenteral nutrition is covered. Only one pump at any one time (stationary or portable) will be covered  Additional pumps will be denied as not reasonable and necessary.
  • If the coverage requirements for parenteral nutrition are met,
  • • (B4220 or B4222): one supply and one administration kit per day  will be covered for each day that parenteral nutrition is administered. 

• Non-covered items or conditions:
• Billing reminders:

Enteral Nutrition Therapy

Nutrients

• HCPCS: Enteral formulas consisting of semi-synthetic intact protein/protein isolates (B4150 or B4152) are appropriate for the majority of beneficiaries requiring enteral nutrition. The medical necessity for special enteral formulas (B4149, B4153-B4155, B4157, B4161, and B4162) must be justified in each beneficiary. If a special enteral nutrition formula is provided and if the medical record does not document why that item is medically necessary, it will be denied as not reasonable and necessary.
• Coverage requirements:  Enteral nutrition is covered for a beneficiary who has (a) permanent non-function or disease of the structures that normally permit food to reach the small bowel or (b) disease of the small bowel which impairs digestion and absorption of an oral diet, either of which requires tube feedings to provide sufficient nutrients to maintain weight and strength commensurate with the beneficiary's overall health status.
• •  Coverage is possible for beneficiaries with partial impairments - e.g., a beneficiary with dysphagia who can swallow small amounts of food or a beneficiary with Crohn's disease who requires prolonged infusion of enteral nutrients to overcome a problem with absorption.
• Frequency limitations:  units of service needed per day  Nutrient solutions for parenteral therapy are routinely covered. Medicare pays for no more than one month’s supply of enteral nutrients at any one time
• Non-covered items or conditions:
• • Enteral nutrition products that are administered orally and related supplies 
  • Food thickeners (B4100), baby food, and other regular grocery products that can be blenderized and used with the enteral system
  • Codes B4102 and B4103 describe electrolyte-containing fluids 
  • Self-blenderized formulas
  • Code B4104 is an enteral formula additive. The enteral formula codes include all nutrient components, including vitamins, mineral, and fiber. Therefore, code B4104 will be denied as not separately payable.
  •  Enteral nutrition is non-covered for beneficiaries with a functioning gastrointestinal tract whose need for enteral nutrition is due to reasons such as anorexia or nausea associated with mood disorder, end-stage disease, etc.
• Billing reminders:
• • If two enteral nutrition products, which are described by the same HCPCS code, are being provided at the same time, they should be billed on a single claim line with the units of service reflecting the total calories of both nutrients.

Supplies: Pump and equipment

• HCPCS: supply allowance (B4034-B4036)  include all supplies, other than the feeding tube and nutrients, required for the administration of enteral nutrients to the beneficiary for one day. These supplies include, but are not limited to, a catheter/tube anchoring device, feeding bag/container, flushing solution bag/container, administration set tubing, extension tubing, feeding/flushing syringes, gastrostomy tube holder, dressings (any type) used for gastrostomy tube site, tape (to secure tube or dressings), Y connector, adapter, gastric pressure relief valve, declogging device, etc.. 
• Coverage requirements: Enteral NUTRITION is considered reasonable and necessary for a patient with a functioning gastrointestinal tract who, due to pathology to, or non-function of, the structures that normally permit food to reach the digestive tract, cannot maintain weight and strength commensurate with his or her general condition
• Frequency limitations:
• • The unit of service (UOS) for the supply allowance (B4034-B4036) is one (1) UOS per day. Claims that are submitted for more than one UOS per day for HCPCS codes B4034-B4036 will be rejected.
  • More than three nasogastric tubes (B4081-B4083), or one gastrostomy/jejunostomy tube (B4087-B4088) every three months is not reasonable and necessary.
• Non-covered items or conditions:
• Billing reminders:

Modifiers

• BA – Item furnished in conjunction with parenteral enteral nutrition (PEN) services: When an IV pole (E0776) is used for enteral nutrition administered by gravity or a pump, the BA modifier should be added to the code. Code E0776 is the only code with which the BA modifier may be used.
• BO – Orally administered nutrition, not by feeding tube. When enteral nutrients (B4149-B4162) are administered by mouth, the BO modifier must be added to the code. 
  
• EY – No physician or other licensed health care provider order for this item or service

Nutritional Supplementation

• HCPCS: 
• Coverage requirements
• Frequency limitations: non-covered
• Non-covered conditions: 

• Billing reminders: 
•