Experienced hme providers know that government regulators review Medicare claims for some types of equipment and supplies more closely than others. Often, this increased scrutiny is based on a belief that a certain product is especially subject to fraud or abuse. Sometimes, the special interest is based on the need for cost containment.

Regardless of the cause for the heightened interest, Medicare fraud investigators expect providers to have documentation to establish medical necessity as determined by the reimbursement program’s guidelines. Enteral nutrition therapy is one of the benefits that appears to be subject to increased scrutiny, so you must educate employees on proper claim documentation.

Enteral Nutrition 101
Enteral nutrition therapy (enteral feeding), sometimes called tube feeding, is a means of giving nourishment to people who cannot swallow because of medical problems. In enteral feeding, a person is fed a liquid formula through a tube, which is inserted into the stomach or intestine through the nose or a surgical opening. The formula can be fed by gravity, syringe, or pump.

Medicare covers enteral feeding under the prosthetic device benefit because it replaces an absent or malfunctioning body part needed to deliver nutrition to the digestive tract. HME used during enteral feeding can include infusion pumps and intravenous (IV) poles. Nutrient formula, tubing, and bags to hold the nutrient are common enteral feeding supplies. Medicaid and most other third-party payors routinely cover enteral feeding when the beneficiary has an anatomical or physiological malfunction of the gastrointestinal tract that makes enteral feeding the exclusive source of nutrition.

Enteral feeding differs from parenteral feeding in that parenteral feeding involves the infusion of a nutrient liquid solution through the use of an indwelling catheter and an infusion pump. Parenteral feeding is also covered under Medicare’s prosthetic device benefit when a severe permanent disease of the gastrointestinal tract prevents a person from absorbing needed nutrients to maintain the weight and strength commensurate with the person’s health status.

The Department of Health and Human Services Office of Inspector General (OIG) reviews Medicare payments for enteral and parenteral feeding on a regular basis. The OIG’s Web site, www.oig.dol.gov, discloses at least five major evaluations of enteral and parenteral feeding Medicare reimbursement policies since 1992. None have reported significant fraud or abuse by providers. For example, a June 1997 OIG report entitled Enteral Nutrition Therapy: Medical Necessity, OEI-03-94-00022 was specifically conducted to determine if Medicare Part B enteral therapy claims in 1995 met Medicare guidelines for medical necessity. The report found that 80% of claims were medically necessary, 3% were unnecessary, and 17% had insufficient or contradicting documentation. Nonetheless, all the reports since 1992 were critical of the costs of enteral and parenteral feeding claims and urged the Centers for Medicare & Medicaid Services (CMS) to contain costs.

Start with Documentation
As with any expensive program covered by Medicare, claim payment for enteral feeding therapy is based in part on a valid certificate of medical necessity (CMN) and sufficient supporting documentation. All third-party payors require either a CMN or a physician’s prescription. Filing for Medicare reimbursement, however, requires more documentation than when filing for reimbursement from other payors. Documentation in Medicare claims must establish the permanent malfunction of the gastrointestinal tract, the specific category of nutrient and caloric intake, and any basis of using an infusion pump.

HME providers filing claims for Medicare reimbursement should ensure that the employees completing the claim have a through understanding of the medical policies and guidelines contained in the appropriate carrier manual. Medicare reimbursement requires a permanent medical condition that either inhibits the delivery of food to the small bowel or prevents the small bowel from digesting and absorbing oral intake. Either condition must also require enteral feeding to provide the beneficiary with sufficient nutrients. A functioning gastrointestinal tract disqualifies a beneficiary for reimbursement even if enteral feedings are appropriate for another medical condition, such as anorexia or nausea.

In general, Medicare will not reimburse for enteral feeding administered orally or as a supplement to oral intake. However, beneficiaries who can swallow small amounts of food can still qualify for Medicare coverage if the beneficiary needs enteral feeding to achieve sufficient caloric intake to maintain weight and strength.

While Medicare guidelines require a qualifying medical condition to be permanent, that does not mean that there is no hope for improvement in the medical condition. If the attending physician’s judgment, supported by clinical documentation, reflects that the beneficiary’s qualifying medical condition is of a long and indefinite duration (ordinarily at least 3 months), Medicare considers the test of permanence met under its guidelines.

The CMN format for enteral feeding is contained in the carrier manual. As with all CMNs, the physician or the physician’s agent must complete Section B without specific prompting by the HME provider. However, once the CMN returns to the HME provider, the provider should check Section B to ensure that the physician or the physician’s agent answered all questions and no contradictory information was provided. For example, the “estimated length of need” block should reflect a permanent condition as described in the carrier manual. In addition, the diagnostic (ICD-9) codes selected by the physician should reflect a condition that can either inhibit the delivery of food to the small bowel or prevent the small bowel form digesting and absorbing oral intake.

Know the Formula Categories
CMS reimbursement rules assume that most beneficiaries will only require a formula consisting of semisynthetic intact protein/protein isolates (Medicare Part B enteral nutrient category I) and an amount sufficient to provide a total caloric intake of 20 to 35 calories per kilogram of body weight per day.

Providers may order formulas with natural intact protein/protein isolates (category IB) for beneficiaries with an allergy to category I formulas if medical necessity is supported by clinical documentation. Calorie-dense formulas (category II) have similar medical necessity requirements.

Other formulas, categories III-VI, require documentation that caregivers tried a category I formula and found it unsatisfactory, or that the attending physician determined that a trial of a category I formula was contraindicated. For example, a specific category III-VI formula may be appropriate for a specific medical condition as reflected in the ICD-9 code.

In addition, an amount of formula ordered reflecting a caloric intake of less than 20 or more than 35 calories per kilogram of body weight per day requires additional documentation. Keep in mind that the potential for mathematical errors in converting body weight from pounds to kilograms (one kilogram = 2.205 pounds) is high, so check calculations to prevent a rejected claim due to a simple mistake.

Use of an enteral feeding pump in lieu of gravity or syringe feeding also requires additional documentation. According to CMS guidelines, common reasons for ordering a pump include, but are not limited to, reflux or aspiration, severe diarrhea, dumping syndrome, blood glucose fluctuations, circulatory overload, or the use of a jejunostomy tube. Regardless of the justification, Medicare requires documentation of the cause.

HME providers must send documentation for feeding pumps and category IB or III-VI formulas with the initial certification and keep a copy in the beneficiary’s file. They must also seek a new CMN and recertification if any patient information, such as the estimated length of impairment, the number of calories per day fed, or the method of administration, changes. Finally, they must know that claims for payment for prospective feedings may not exceed 30 days’ worth of supplies.

With enteral nutrition therapy claims, it pays to be careful. Submitting valid claims requires ensuring the claim file contains certain basic information. Educate employees about claim guidelines and, because the delivery of enteral nutrition supplies may involve extended service, be attuned to changes ordered by the attending physician. With a little extra attention, you can minimize your claim-denial and fraud-investigation risk.

Glen D. Sanborn, JD, is an attorney with the Health Care Group of Brown & Fortunato, PC, Amarillo, Tex. He can be reached at (806) 345-6346 or gsanborn@bf-law.com.