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Documentation | 2012 MEDICARE PART B RATES* — NESTLE HEALTHCARE NUTRITION PRODUCTS • Tube feeding administered by pump. Gravity feeding is Blenderized natural foods with intact nutrients COMPLEAT®, COMPLEAT® PEDIATRIC, COMPLEAT® PEDIATRIC REDUCED CALORIE Nutritionally complete with intact nutrients BOOST®, BOOST® HIGH PROTEIN, FIBERSOURCE® HN, ISOSOURCE® HN, NUTREN® 1.0, NUTREN® 1.0 FIBER, OPTIFAST HP® SHAkE MIx, OPTISOURCE® HIGH PROTEIN DRINk, REPLETE®, REPLETE® FIBER Nutritionally complete, calorically dense with intact nutrients BOOST PLUS®, BOOST® VHC, ISOSOURCE® 1.5 CAL, NUTREN® 1.5, NUTREN® 2.0, RESOURCE® 2.0 – Administration rate less than 100 ml/hr; or Nutritionally complete, hydrolyzed proteins (amino acids and peptide IMPACT® GLUTAMINE, IMPACT® PEPTIDE 1.5, PEPTAMEN®, PEPTAMEN® with PREBIO¹™, PEPTAMEN AF® PEPTAMEN® 1.5, PEPTAMEN® 1.5 with – Gastrostomy/jejunostomy tube used for feeding PREBIO¹™, PEPTAMEN® BARIATRIC, TOLEREx®, VIVONEx® PLUS, VIVONEx® RTF, VIVONEx® T.E.N. BOOST GLUCOSE CONTROL®, DIABETISOURCE® AC, GLYTROL®, IMPACT®, IMPACT ADVANCED RECOVERY®, • Use of formulas B4149, B4153-B4157, B4161 and B4162 Nutritionally complete, for special metabolic needs, excludes inherited IMPACT® with Fiber, NOVASOURCE® RENAL, NUTREN® PULMONARY, NUTRIHEP®, RENALCAL®, RESOURCE® BREEZE, RESOURCE® requires documentation of medical necessity describing why the patient cannot or should not utilize standard formulas, B4150 or B4152. These products are prescribed for specific Nutritionally incomplete/modular nutrients; INCLUDES SPECIFIC conditions or diseases and medical documentation provided NUTRIENTS, CARBOHYDRATES (E.G. GLUCOSE POLYMERS), MCT OIL®, MICROLIPID®, ARGINAID®, BENECALORIE®, BENEPROTEIN®, GLUTASOLVE® should reflect both the functional impairments of digestion PROTEINS/AMINO ACIDS (E.G. GLUTAMINE, ARGININE), FAT (E.G. and absorption, and the need for special formula MEDIUM CHAIN TRIGLYCERIDES) OR COMBINATIONB4102 documentation in the Patient’s Medical record Formulas that are used to replace fluids and electrolytes CMs Manual system, Pub. 100-08, Medicare Program integrity Manual, Enteral formulas, for pediatrics, nutritionally complete calorically NUTREN JUNIOR®, NUTREN JUNIOR® FIBER, BOOST® kID ESSENTIALS, BOOST® kID ESSENTIALS 1.5, BOOST® kID ESSENTIALS 1.5 with FIBER for any dMePos item to be covered by Medicare, the patient’s medical dense (equal to or greater than 0.7 kcal/mL) with intact nutrients record must contain sufficient documentation of the patient’s medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable). The Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide PEPTAMEN JUNIOR®, PEPTAMEN JUNIOR® 1.5, PEPTAMEN JUNIOR® WITH PREBIO¹™, PEPTAMEN JUNIOR® FIBER, VIVONEx® PEDIATRIC information should include the patient’s diagnosis and other pertinent information including, but not limited to, duration of the patient’s condition, clinical course (worsening or improving), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, past experience with related items, etc. if an item requires a CMn or dif, it is recommended that a copy of the completed CMn or dif be kept in the patient’s record; however, neither a physician’s order, nor a CMn nor a dif nor a supplier-prepared statement nor physician attestation by itself enteral supplies, Tube and Pump information provides sufficient documentation of medical necessity, even though it is signed by the treating physician or supplier. There must be information Claims for HCPCs Codes B4149, B4153–B4157, B4161, and B4162 will be denied as not reasonable and * enTeral forMulas administered through an enteral tube. Medicare will not pay for formulas in the patient’s medical record that supports the medical necessity necessary unless the coverage criteria for specialty nutrients are met. if not met, suppliers have the taken orally. if submitting Medicare claim for denial, add the “Bo” modifier.
for the item and substantiates the answers on dif or information on a option of using the upgrade modifiers as noted in the recent dMe MaC publication on use of upgrade ** Medicare Part B fee for service Payment rates can be found at: Modifiers. The clinical documentation information included herein has been provided for illustrative https://www.dmepdac.com/dmecsapp/do/search supplier-prepared statement or physician attestation (if applicable). The purposes only and does not constitute legal or reimbursement advice. Policies and regulations † These rates reflect the national fee schedule and does not reflect Competitive Bidding rates.
patient’s medical record is not limited to the physician’s office records. it change frequently and are subject to interpretation and that the entity submitting claims must assure may include hospital, nursing home, or home health agency records and itself that the reimbursement information is accurate and applicable to the claim being filed. Current records from other professionals including, but not limited to, nurses, Medicare Part B information is also available at https://www.cms.gov/.
physical and occupational therapists, prosthetists, and orthotists.
Please noTe: The reimbursement information contained in this publication is gathered from https://www.cms.gov/manuals/downloads/pim83c05.pdf third party sources and is presented for illustrative purposes only. This information should not be interpreted as a guarantee of reimbursement or as endorsed by Medicare, Medicaid, or an insur- ance Carrier. Billing entities should contact their third-party payers for specific information on their coding, coverage and payment policies. While this publication provides examples of clinical information that may be pertinent in seeking enteral coverage for a beneficiary, it does not constitute for additional information on nestlé nutrition products, please contact your constitute legal or reimbursement advice.
a recommendation related to a medical necessity determination or the documentation that should be local nestlé HealthCare nutrition sales representative, or call infolink Product provided in connection with a given patient or claim. all medical necessity determinations must be Policies and regulations change frequently and are subject to made by the responsible clinician(s). in addition, the actual documentation used to support a given interpretation. The entity submitting claims must assure itself claim must be true in all respects and accurately represent the individual beneficiary’s condition and www.NestleHealthScience.us • All trademarks are owned by that the reimbursement information is accurate and applicable to circumstances. The person or entity submitting claims for reimbursement is solely responsible for ensuring the appropriate filing and accurate content of any particular claim. Persons who submit société des Produits nestlé s.a., Vevey, switzerland. 2012 nestlé. the claim being filed. Current Medicare Part B information is also false or fraudulent claims for reimbursement are subject to significant civil and criminal penalties.
Peptamen®**, Peptamen af™**, Peptamen® Peptamen af™**, Peptamen® 1.5**, Peptamen® 1.5 with Prebio¹™**, immune-moDulaTing, HigH Pro- low FaT, Free amino aCiD Formula For ProTein elemenTal DieTS For Tal DieT For STreSSeD STreSSeD PaTienTS anD THoSe PaTienTS wiTH a Bmi ≥ 30 anD Trauma PaTienTS wiTH or Protein malnutrition and/or increased Weight loss Patient experienced worsening of Persistent nausea and/or vomiting - Persistent elevated blood glucose levels Elevated serum electrolytes requiring Persistent nausea and/or vomiting Increase in size or stage of pressure ulcer Progressive chronic renal failure with Post-fundoplication dumping syndrome Increase in size or stage of pressure ulcer Adiposity in the absence of overfeedingReduced bone mass Malabsorption confirmed by laboratory tests Malabsorption confirmed by laboratory tests Severe electrolyte imbalance, Elevated Malabsorption confirmed by laboratory tests Reduced energy needs confirmed by indirect calorimetry or excessive weight gain in the absence of overfeeding.
OsteopeniaLow vitamin D status confirmed by laboratory tests Regional enteritis/Crohn’s (555.0-558.9) Diagnosis noted in previous column and the Regional enteritis/Crohn’s (555.0-558.9) Acute and subacute necrosis Acute renal failure (584.5-584.9) Benign neoplasm of Islets of Langerhans (211.7) Vascular insufficiency of intestine (557.0-557.9) Vascular insufficiency of intestine (557.0-557.9) Superior mesenteric artery syndrome (557.1) Superior mesenteric artery syndrome (557.1) Chronic respiratory failure (518.83-518.84) cirrhosis (571.0-571.9) Post-gastric surgery syndromes (includes dumping syndrome) (564.2) Open wound of head, neck, or trunk (870.0-879.9) Bilious Vomiting following gastric surgery (564.3) Disorders of pancreatic secretion (251.8-.9) Open wound of head, neck, or trunk (870.0-879.9) Other specified intestinal malabsorption (579.8) Other specified intestinal malabsorption (579.8) Post-operative pulmonary insufficiency (518.5) Other and unspecified protein-calorie malnutrition (263.0-263.9) Chronic respiratory failure (518.83-518.84) Complications of intestinal anastomosis and bypass (997.4) Complications of intestinal anastomosis and bypass (997.4) Abnormal glucose tolerance test (790.22) Other and unspecified protein-calorie malnutrition Blind loop syndrome (579.2) Trauma–Motor Vehicle Traffic Accidents (E810- Accident caused by firearm missile (E922) Assault by cutting and piercing instrument (E966) Pseudo-obstruction of intestine (560.89-560.9; 564.89) Pseudo-obstruction of intestine (560.89-560.9; 564.89) Document malabsorption as noted in previous Indications listed in previous columns , Results of trials with other formulas Hypocaloric agents and response calories/day Results of tube placement/administration method changes in addition to BMI ≥ 30 and/or very high Results of tube placement/administration method Results of tube placement/administration method changes during use of standard formula (to assure that Results of tube placement/administration method changes Laboratory tests documenting malnutrition: albumin, prealbumin, Laboratory tests documenting malnutrition: albumin, prealbumin, Conditions documenting Sepsis: temperature, heart transferrin, vitamin levels Inadequate blood glucose control: HgbA1C and/or not overfed Radiographic studies documenting transit time Laboratory tests confirming malabsorption: fecal fat, d-xylose Protein and/or energy needs, calculations rate, respiratory rate, white blood cell count, Laboratory tests confirming malabsorption: fecal fat, d-xylose fructosamine levels, blood glucose levels (multiple), Ventilator settings Laboratory tests documenting malnutrition: albumin, prealbumin, transferrin, insulin dosage, c-reactive protein levels Order for fluid and protein restrictions vitamin levels Anergy: total lymphocyte count, skin testing, Weight changes Radiographic motility studies Laboratory tests confirming malabsorption: fecal fat, d-xylose Protein and/or energy needs, calculations Evidence of skin breakdown due to diarrhea Evidence of skin breakdown due to diarrhea Laboratory tests documenting malnutrition: iCd-9-CM for Physicians–Volumes 1 and 2 2008 expert ingenix Progress notes ruling out infections or medication induced diarrhea albumin, prealbumin, transferrin, vitamin levels Progress notes ruling out infectious or medication induced diarrhea (If medi- ** PePTaMen formulas contain ingredients (i.e., partially hydrolyzed whey protein from cow’s milk protein) that may not be Evidence of skin breakdown due to diarrhea appropriate for individuals with food allergies.
(If medication change not possible, document formula use to amelo- Trauma indications: Injury Severity Score ≥ 18, cation change not possible, document formula use to ameliorate diarrhea) *** These formulas are not hypoallergenic. riate diarrhea) Surgery or pathology reports confirming gastric, Abdominal Trauma Index ≥ 20, Glasgow Coma Surgery or pathology reports confirming gastric, pancreatic or bowel **** renalCal is not intended for long-term tube feeding use as it does not contain electrolytes. Consult your nutrition professional Progress notes ruling out infections or medication-induced diarrhea (If medica- pancreatic or bowel resection or bypass.
Scale < 8, Burns ≥ 30% of total body surface area tion change not possible, document formula use to ameloriate diarrhea)

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