July 2, 2009
Lessons Learned: Enteral Nutrition
The CIGNA Government Services’ Medical Review staff recently completed a series of provider- and service-specific post payment probe reviews on the top 50 Jurisdiction C billers (measured by units billed/beneficiary) of HCPCS code B4150. These reviews were conducted as a result of data analysis based on the November 2007 CERT Error Report. This report indicated that Jurisdiction C had a high paid claims error rate for enteral nutrition.
The probe reviews verified the CERT data. Of the nine suppliers chosen for provider-specific reviews, eight had error rates above 50%. The error rate of the 123 claim service-specific review was 91.43%.
The following reminders are based on errors identified in the reviews.
Proof of Delivery
- When suppliers utilize the mail or a shipping service to delivery supplies,
the following rules apply:
- The date of service billed shall be the shipping date.
- Tracking information (invoices, internet tracking printouts, etc.) has to be detailed enough that a reviewer can determine what was shipped, who it was shipped for, where it was shipped and confirmation that the shipment was delivered.
- It is permissible, when sending supplies to nursing homes, to combine supplies for multiple beneficiaries. However, the tracking information shall include an individual breakdown of nutrients and supplies billed for each beneficiary.
- Regulations that apply when a supplier personally delivers
the items billed include:
- The date of delivery is the date of service that shall be billed.
- The delivery slip should include sufficient information for the reviewer to be able to confirm that all items were correctly coded. For example, the name of the nutrient should be listed.
- When someone other than the beneficiary signs for delivery, the designee’s relationship to the beneficiary should be listed.
- The beneficiary or designee should personally date his/her signature. This date, if the delivery slip contains multiple dates, will be considered the official date of delivery.
Detailed Written Order
- Enteral nutrients and supplies may be delivered based on a preliminary dispensing order (written, fax or verbal). Suppliers are required to include written documentation of this order in the beneficiary’s file and it shall contain the beneficiary’s and physician’s names, a description of the item(s) and the date of the order. If a Medicare contractor (CERT, DME MAC, RAC, PSC/ZPIC) requests supporting documentation for items dispensed based on a preliminary order, the supplier should submit a copy of this order as well as the detailed written order.
- Suppliers are reminded
that items cannot be billed to Medicare prior to obtaining a detailed written
order. The required elements for a detailed written order for enteral nutrition
and supplies are:
- Beneficiary's name;
- Description or name of the nutrient to be administered;
- Method of administration (syringe, gravity or pump);
- Rate/frequency of administration;
- List of all additional items to be dispensed and billed;
- The treating physician's signature (stamped signatures are not acceptable);
- The physician’s personally entered signature date; and
- The start date of the order (only required if the start date is different than the signature date).
- When a nurse documents a verbal or telephone order from a physician, this order may serve as a preliminary dispensing order but it is not a valid detailed written order until the physician personally co-signs and dates that order and it contains the required elements listed above.
Medical Necessity
- Coverage of Enteral Nutrition is paid under Medicare’s prosthetic
benefit which requires that the patient have a permanently (three months
or longer) non-functioning internal body organ. In the case of enteral nutrition,
this means the patient shall have:
- a permanent non-function or disease of the structures that normally permit food to reach the small bowel; or
- disease of the small bowel which impairs digestion and absorption of an oral diet; and
- The patient requires tube feedings to provide sufficient nutrients to maintain weight and strength commensurate with the patient's overall health status.
- Covered conditions could be either anatomic (e.g., obstruction due to head and neck cancer or reconstructive surgery, etc.) or due to a motility disorder (e.g., severe dysphasia following a stroke, etc.).
- Enteral nutrition is non-covered for patients 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.
- Nutritional supplementation is not covered under Medicare Part B. Examples of supplemental nutrition include situations where a patient is able to eat but enteral nutrition is ordered to boost the patient’s protein-caloric intake or is the mainstay of a daily nutritional plan.
- In the event of a claim review, suppliers are required to submit actual medical records (no checklists, attestation statements, etc.) that support the patient has a covered condition.
Other Issues
- Suppliers billing for enteral nutrition are required to complete, sign and date a DME MAC Information Form (DIF) for Enteral and Parenteral Nutrition prior to billing Medicare.
- DIFs are OMB-approved forms which the supplier cannot alter by adding a company logo, a line for physicians to sign, etc.
- Suppliers shall contact the beneficiary prior to dispensing refill supplies. Contact with the beneficiary or designee regarding refills should take place no sooner than approximately seven days prior to when the existing supplies are expected to be exhausted.
- Shipment or direct delivery of new
supplies should be no sooner than approximately five days prior to the
end of usage for the current product.
