Enteral nutrition is the provision of nutritional requirements through a tube into the stomach or small intestine.

It is covered by Medicare for patients with diseases or structural defects of the alimentary tract that interfere with transport, digestion or absorption of nutrients to a degree that oral ingestion proves inadequate to maintain weight and strength commensurate with overall health status. Such conditions may include anatomic obstructions such as head and neck cancers, or motility disorders such as dysphagia or gastroparesis. Even neurological disorders (eg., Alzheimer's) resulting in this degree of ingestional dysfunction would qualify for coverage. The severity of these conditions which warrants coverage is reflected in the physician's decision to insert and maintain a feeding tube in the patient. Coverage is possible for patients with partial impairments - e.g., a patient with dysphasia who can swallow small amounts of food or a patient with Crohn's disease who requires prolonged infusion of enteral nutrients to overcome a problem with absorption. Questions often arise about patients whose conditions are either improving or deteriorating and may be transitioning to or from a tube-feeding situation. They may be getting some of their nutrients orally, but require tube feedings to maintain their nutritional status. So long as the physician sees fit to maintain the enteral tube, Medicare will cover those nutrients administered via that tube. In order to be covered, the physician must judge the condition to be permanent - expected to last greater than three months, or until the patient's death, whichever is shorter.

Conditions which are not covered (even though they may involve tube feedings) include anorexia and nausea, secondary to mood disorders and end-stage diseases not directly involving the gastrointestinal tract.

Only those nutrients administered via the feeding tube are covered by Medicare. (Enteral nutrients taken orally are not covered by Medicare.) Baby food and blenderized grocery products are not covered, even if administered via a feeding tube. Medicare pays for supplies required for different methods of administering tube feedings (gravity, syringe or a pump). Medical records should reflect medical conditions requiring controlled administration of nutrients through a pump. More than one nasograstric tube per month or one gastrojejunostomy tube every 3 months are rarely medically necessary. (While disoriented patients may remove their own tubes leading to the use of more tubes, such an occurrence is not considered strictly an issue of medical necessity and is not reimbursable.) Dressings used for the insertion site of enteral tubes are reimbursed as part of the "administration kit," and are not separately payable.

Most enteral nutrient products sufficient to achieve and maintain adequate nutritional status are grouped into a basic HCPCS billing code (B4150) and are reimbursed at the same rate. Products made of natural intact protein (HCPCS code B4151) are covered for patients who have demonstrated an allergy or intolerance to the basic semi-synthetic products. Special, more highly reimbursed products (HCPCS codes B4153-B4155) need to be justified for each patient. The physician must document why he or she is ordering these products (such as those that are disease-specific).

Documentation for claims with Dates of service on or before January 1, 2007

If you ordered enteral nutrition for your patient on of before January 1, 2007, it is necessary to complete a Certificate of Medical Necessity (CMN), in order for the supplier to be reimbursed by Medicare. The physician is expected to have seen the patient within 30 days prior to initially certifying the need for enteral nutrition, or document why not, and what monitoring methods were used to evaluate the patient's enteral nutrition needs.

Section B of the CMN contains questions pertaining to the medical necessity of the equipment which may not be completed by the supplier. The physician or another health care clinician may complete Section B, but only the patient's treating physician may sign the CMN, indicating that he/she has reviewed Section B of the CMN for accuracy and completeness.  The patient's medical records must contain documentation substantiating that the patient's condition meets the above coverage criteria and the answers given in Section B of the CMN. These records may be requested by the DMERC to confirm corroboration by the medical record of the information submitted to the DMERC.

The following link is the required CMN that needs Section B to be completed by the physician before a prescription can be accurately billed to Medicare. This form needs to be printed as one page, front and back, and then given to the pharmacy so they can bill to Medicare.

CMN for claims before January 1, 2007

Documentation for claims with Dates of service after January 1, 2007

CMS has revised the CMN form for the Enteral and Parental nutrition.  For claims dated after January 1, 2007 the DME information form (DIF) 10.03 is required to be filled out by the supplier. The physician’s signature is no longer required, however you will need to still document in patient’s medical records regarding conditions.  CMS can request additional documentation at any time.

The following link is the required DIF, along with instructions, that the pharmacy must fill out and then submit to Matrix.  Matrix will contact the pharmacy once completed to allow them to process the prescription.