The Centers for Medicare & Medicaid Services (CMS) has released a video that contains guidance to help providers bill correctly for enteral infusion pumps.

Medicare Part B covers enteral nutrition supplies and equipment (feeding pump) under the prosthetic device benefit.

The two-minute video discusses Medicare coverage criteria for enteral infusion pumps and the four pieces of information necessary for proper documentation.

As CMS noted in September, there are a number of reasons for denial:

  • The patient must have a permanent (ordinarily at least three months) non-function or disease of the structures that normally permit food to reach the small bowel or a disease of the small bowel which impairs digestion and absorption of an oral diet. Either condition must require tube feedings to provide sufficient nutrients to maintain weight and strength commensurate with the patient’s overall health status.
  • When the method of administration is via enteral infusion pump, there must be documentation in the medical record to justify the use (for example, gravity feeding is not satisfactory due to reflux and/or aspiration, severe diarrhea, dumping syndrome, administration rate less than 100 ml/hr, blood glucose fluctuations, circulatory overload, gastrostomy/jejunostomy tube used for feeding). If the medical necessity of the pump is not documented, the pump will be denied as not reasonable and necessary.
  • The enteral nutrition must be infused 7 days per week. Documentation requirements include a detailed written order (DWO) for each item billed that must be signed and dated by the treating physician and a DME information form (DIF), which has been completed, signed, and dated by the supplier. Both of these must be kept on file by the supplier and made available upon request.
  • A new initial DIF for a pump is required when: a formula billed with a different code, which has not been previously certified, is ordered; enteral nutrition services involving use of a pump are resumed after they have not been required for two consecutive months; or a beneficiary receiving enteral nutrition by the syringe or gravity method is changed to administration using a pump
  • A revised DIF for enteral nutrients is required when: the number of calories per day is changed; the number of days per week administered is changed; the method of administration (syringe, gravity, pump) changes; the route of administration is changed from tube feedings to oral feedings (if billing for denial); or the HCPCS code for the current nutrient changes.

The video is part of a series intended to help providers improve in areas identified with a high degree of noncompliance.

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