Medicare Enteral and Parenteral Reimbursement: Requirements for Successful Coverage and Payment

Suppt Line August 2006 Volume 28 No. 4 Medicare Enteral and Parenteral Reimbursement: Requirements f Successful Coverage and Payment Frank R. Wojtylak, RD/CDN Abstract Clinical codination, moniting, documentation, and consistency are the key issues related to obtaining favable Medicare coverage. The Centers f Medicare and Medicaid Services outline specific requirements related to medical conditions f which enteral and parenteral nutrition may be the therapy of choice. Medicare outlines specific criteria with guidelines that must be addressed f proper payment. This article provides a brief overview of the requirements f successful reimbursement along with the documentation required. Introduction Medicare is a federal program enacted by Congress as part of Title 18 of the Social Security Act of 1965. It is the largest insurance program in the United States. Medicare is one of the most challenging pays f home infusion therapy. Medicare coverage is divided into Parts A, B, C, and D, each of which provides different covered benefits (Table 1). Enrolling in Part B Medicare is strictly the choice of the recipient/ beneficiary. Medicare Part B covers home infusion therapy under prosthetic devices because parenteral nutrition and enteral tube feeding replace the nmal al route of receiving nutrition. Medicare Eligibility/Coverage Medicare is available to select recipients. To qualify f Medicare coverage, an individual must be: 65+ years of age Entitled to Social Security benefits and/ Railroad Retirement Younger than age 65 years, but disabled f >2 years Younger than age 65 years, with end-stage renal disease F purposes of management, Medicare beneficiaries are assigned to one of four Durable Medical Equipment Regional Carrier (DME MAC) regions (based on their permanent address). The DME MACs will be the governing and codinating entities that administer federally mandated Medicare policy (Table 2). Qualification f Home Nutrition Therapy To qualify patients f Nutritional Coverage (Parenteral and Enteral Nutrition)/Therapy (Part B Medicare), the following must be ascertained: Has the patient/beneficiary been qualified f services under Part B Medicare? Has this infmation been confirmed? When does the patient turn age 65? What is the state of primary residence of the recipient? (This determines in what jurisdiction the patient will be processed.) Table 1. Medicare Covered Benefits Medicare Part A Inpatient health coverage Intermittent skilled care Rehabilitation treatment Sht-term skilled nursing therapy Hospice care Some medical equipment/supplies Blood/blood products Medicare Part B Outpatient hospital services Physician services and advanced practice nurse services Emergency department visits and services Labaty services and diagnostic tests Home health services not covered under Part A Durable medical equipment and supplies Medical nutrition therapy Prosthetic devices Is the patient spouse the primary holder of the insurance? Are there other supplemental insurances that may affect overall coverage? What is the duration of the services provided? Are specific criteria obtained f provision of services under Medicare policy? Are the patient, health-care practitioner, and health-care providers in agreement with sound, longterm plans of care? Is the patient fully infmed of services provided and costs associated with the therapy he she is receiving? Is there anatomic impairment to the gastrointestinal tract and a need f permanent ongoing long-term therapy? Medicare Part C Programs that might help an individual to pay health care costs that Medicare does not cover* Medicare Part D Prescription drug costs *Me details can be found at: www.medicare.gov in the Personal Plan Finder section. 18

Suppt Line August 2006 Volume 28 No. 4 Enteral Therapy A number of parameters must be documented when providing enteral therapy f patients/beneficiaries with Medicare benefits. Governing rules f coverage may be found at: http://www. cignamedicare.com/articles/jan05/ Cope1879.html. Among the infmation that must be fully documented is: Does the patient/beneficiary meet the need f permanence of enteral therapy? Permanence is defined by Medicare as me than 90 days. Is there documentation that the patient is receiving enteral therapy by means other than ally (showing that the patient is not taking his/her fmula ally as a supplement)? Is there an identified diagnosis of impaired gastrointestinal dysmotility inability to swallow, as evidenced by objective testing and ICD-9 code? Is there documented evidence of disease that prevents food nutrition from reaching the bowel and being absbed? Is there a documented trial of a lower B-code befe use of a specialty enteral fmula when a specialty product is required? Is there an ongoing program of moniting patient/beneficiary compliance with the therapy established? Is there a signed Certificate of Medical Necessity (CMN) completed by the physician showing the need and justification f the enteral therapy? Is there documentation showing that the patient requires tube feedings to maintain weight and strength commensurate with overall health status? Is it not possible to provide adequate nutrition by dietary adjustment and/ al supplements? Enteral Pump Assisted Feedings If a patient requires an enteral pump f the therapy, justification of the need and rationale f providing this device is required and can be provided through a statement on the CMN documentation through an ICD-9 code. Common reasons f needing a pump include failure to tolerate gravity feedings due to: Table 2. DME MAC Providers and Web Sites DME MAC Jurisdiction A National Heritage Insurance Company www.medicarenhic.com/dme/index.shtml DMERC B Jurisdiction B Admina Star Federal www.adminastar.com/providers/dmerc/contractrefm/ ContractRefm.html DME MAC Jurisdiction C Palmetto GBA http://www.palmettogba.com/palmetto/palmetto.nsf/template/palmetto/ Home?Opendocument DMERC D Jurisdiction D Nidian http://www.nidianmedicare.com/bene/ Provider s Handbook: http://www.cms.hhs.gov/medicarecontractingrefm/downloads/ DME%20MAC_DME_MAC_Implementation_Handbook.pdf Reflux with potential f aspiration Severe diarrhea Dumping syndrome Required administration of feeding at a rate of less than 100 ml/hr Use of a jejunostomy tube f feedings Blood glucose fluctuations When developing and maintaining the CMN, the clinician should be aware of the differences required f initial, revised, and recertified CMNs. CMN recertifications are based on the timing, such as when the length of therapy exceeds the anticipated time period on the previous CMN, and when there are changes to the prescription, such as a change in the enteral fmula categy. Enteral Documentation Requirements f Medicare Coverage To assist with overall documentation needs and qualification, Medicare has outlined the requirements/documentation required f enteral coverage. A documentation checklist can be downloaded from http://www.cignamedicare.com/dmerc/ mr/cert/pdf/enteral.pdf. When assembling and maintaining documentation on a patient who is receiving enteral therapy, a properly documented patient chart should include: MD ders (updated accdingly) Objective labaty and diagnostic tests Evidence of tube placement Calies, type of feeding, administration instructions Method of administration (e.g., pump, syringe) Appropriate diagnostic codes Ongoing proof of delivery (supplier delivery recds) Ongoing proof of patient compliance (regular calls and clinician moniting recds/assessments) Copy of CMN (enteral CMN) on file Reasons f the need/use of any specialty enteral fmulas When addressing the need use of a specialty enteral fmula, it is imptant to evaluate critically the clinical indications f a specialty fmula based on gan function digestive/absptive capability. Documentation suppting the use of a specialty fmula is required f reimbursement at the higher rate. If documentation is inadequate, the reimbursement rate will be down-coded to the lowest enteral fmula categy. Down-coding is reimbursement at the standard rate when the patient is receiving a specialized fmula that is associated with a higher rate of reimbursement related to its increased cost. This can result in increased costs incurred by the home infusion provider. The following are examples of documentation needed f a specialty fmula: If an elemental enteral fmula is indicated, there must be documentation that a standard fmula resulted in intolerance and changing to the elemental fmula improved (Continued on next page) 19

Suppt Line August 2006 Volume 28 No. 4 tolerance, such as reducing stool output. Justification f a diabetic enteral fmula is improved glucose control with the specialized fmula versus a standard enteral fmula. Objective documentation to suppt the need f a specialized product, such as abnmal fecal fat, D-xylose beta carotene, serial blood glucose measurements, noting elevated status with a standard product and controlled blood glucose values with the specialized product. Parenteral Therapy Conditions f Medicare Coverage To qualify f payment, patients receiving parenteral nutrition must qualify f criteria accding to Medicare Policy. Table 3 lists the conditions f which parenteral nutrition is not covered. To qualify f coverage, the patient must have a permanent impairment of the gastrointestinal (GI) tract that will last a minimum of 3 months. The patient also must have impaired function of the GI tract that has resulted in significant malabsption GI dysmotility. Results of diagnostic tests Table 3. Conditions That Do Not Qualify a Patient f Parenteral Nutrition Under Medicare Swallowing disder Tempary impaired gastric emptying (e.g., metabolic electrolyte disder) Impaired nutrient intake due to depression other psychological disder Anexia related to a metabolic disder (e.g., cancer) Impaired al intake of food with physical disder (e.g., dyspnea of severe pulmonary cardiac disease) Adverse effects of pharmacotherapy End-stage renal disease and procedures must suppt the claim of a malfunctioning GI tract. The most common ICD-9 codes requiring parenteral nutrition under Medicare criteria are listed in Table 4. A decision tree to guide the clinician through the qualification process f home parenteral therapy is shown in the three-part Figure. Criteria f Situation G/H are f patients who do not fit into other situations (e.g., >5 ft of small bowel left, absbing >50% of intake, radiographic contrast reaches right colon after 5 hours). The use of G/H criteria requires me documentation and often is scrutinized me closely when submitted. It frequently requires documentation of an attempted and failed tube feeding trial. Definition of a Tube Trial A concerted efft must be made to place a feeding tube. F gastroparesis, tube placement must be postpylus, preferably in the jejunum. Use of a double-lumen tube should be considered. Adjustments in the enteral fmulation selection, fmula strength, and infusion rate must also be attempted to reduce stool output and improve tolerance befe a tube feeding trial can be said to have failed. Oral Diet with Parenteral Nutrition It is not necessary to keep a patient nil per os (NPO) f Medicare to approve parenteral nutrition coverage. Patients receiving parenteral nutrition are often taking food in small amounts f social reasons as well as to maintain the integrity of the GI tract f its immunologic properties. However, it is imperative to document that al intake alone is insufficient to maintain the strength and weight of the patient. Documentation Accding to the AdminaStar Federal Web Site, a CMN is required f the Medicare patient to qualify f home parenteral nutrition. The CMN f parenteral nutrition must be signed by the physician, but can be completed by the physician s designee as long as the designee is not the home infusion supplier. Regardless of the individual completing the CMN, the prescribing Table 4. Common ICD-9 Codes Associated With Home Parenteral Therapy and Medicare Criteria 263.0 Malnutrition of moderate degree 263.1 Malnutrition of mild degree 536.3 Gastroparesis 555.0 Crohn s/regional enteritis of the small intestine 555.1 Crohn s/regional enteritis of the large intestine 555.2 Crohn s/regional enteritis of the small and large intestine 557.0 Acute vascular insufficiency of intestine 557.9 Unspecified vascular insufficiency of intestine 560.1 Paralysis of the intestine colon 560.81 Intestinal peritoneal adhesions with obstruction 560.89 Other intestinal obstruction 560.9 Unspecified intestinal obstruction 564.9 Unspecified functional disder of intestine 569.81 Fistula of the intestine, excluding rectum and anus 577.0 Acute pancreatitis 577.1 Chronic pancreatitis 577.2 Pancreatitis with cyst/pseudocyst 579.3 Other and unspecified postsurgical nonabsption 579.8 Other specified intestinal malabsption 579.9 Unspecified intestinal malabsption 783.21 Abnmal loss of weight 998.6 Persistent postoperative fistula 20

Suppt Line August 2006 Volume 28 No. 4 physician must attest to the accuracy of the CMN. New CMN guidelines are being developed f implementation in calendar year 2006-2007 that will change many of the current completion requirements. CMN recertifications are based on the timing, such as when parenteral nutrition is given f me than 6 months, the length of therapy exceeds the anticipated time period on the previous CMN, and there are changes to the parenteral nutrition prescription. A nutrition assessment should address the patient s current status in relation to his her status 1 to 3 months pri to the initiation of parenteral nutrition. Energy intake and balance, weight changes, route of feeding and tolerance, and diet prescription and supplements should be noted, as appropriate, within the nutrition assessment. Required Documentation f Any Payment Submission When submitting a claim f payment, specific pieces of documentation are required to achieve favable results. When initial/subsequent claims are submitted, the following documentation may be required: Completed/signed CMN Signed and dated physician ders Letter of Medical Necessity outlining/ summarizing the criteria and reasons f parenteral nutrition and any need f specialized fmulations. Appropriate documentation as required: labaty tests, diagnostic tests, intake/output, histy and physical examination, documented weight histy, progress notes, etc. Consultant/operative repts Objective tests and notations as related to the patient s case (It should be noted that Medicare will not accept unsigned notations, reviews of verbal conversations, generalized statements.) What Happens After Payment Submission? An initial request f payment is submitted to Medicare. The initial infmation is reviewed f accuracy and adherence to Medicare policy. Once reviewed and approved, the payments are sent to the supplier, with acknowledgement fwarded to the patient of charges submitted and payments made. What Can I Do If the Claim Is Denied? When a claim is denied, Medicare sends a copy of the reason f denial to the patient (known as a beneficiary) (Continued on next page) Patient s condition is permanent (at least 3 mos.) Pt. has condition that significantly impairs absption of nutrients pt. has severe motility disder Patient does not meet Medicare coverage criteria f home TPN therapy. TPN Decision Tree Directions: Start in the far left column and examine medical recds as you check f a covered situation. Keep going down the tree as long as you can answer to a criterion. If/When the answer is No move one column to the right and begin going down that column. Continue checking the medical recds against the criteria until you verify that the patient s condition meets a covered situation you determine that the patient does not qualify f home TPN. SITUATION B Situation A Pt. has sht bowel syndrome SITUATION C SITUATION A Pt. had massive small bowel resection leaving < 5 ft. small bowel beyond the ligament of Treitz The surgery occurred within the past 3 months. Situation B Enteral losses exceed 50% of the al enteral intake Oral Intake is at least 2.5-3 l/day Urine Output is < 1 liter per day Situation C Pt. requires bowel rest f at least 3 mos. Pt. is receiving 20-35 cal/kg/day IV Pt. has: * symptomatic pancreatitis * severe exacerbation of regional enteritis * proximal enterocutaneous fistula and tube feeding distal of fistula is not possible Situation D on page 2 Patient meets Medicare coverage criteria f home TPN therapy under Situation A Patient meets Medicare coverage criteria f home TPN therapy under Situation B Patient meets Medicare coverage criteria f home TPN therapy under Situation C 21

Suppt Line August 2006 Volume 28 No. 4 and to the supplier that outlines the reasons f the claim being rejected. At that time, the supplier can appeal the denial and crect/supply additional infmation and/ documentation to reverse the denial. Appeals/Grievances Medicare has specific guidelines related to an appeals process when submitted claims are denied. Should these claims be denied f payment, Medicare uses an appeals process with specific deadlines/timeframes: Deadline Step f Filing Redetermination 120 days from date of receipt of the notice of initial determination. Reconsideration 180 days from the date of receipt of the redetermination. Hearing 60 days from the date of receipt of the reconsideration notice. Departmental 60 days from the Appeals Board date of receipt of the Administrative Law Judge hearing decision/dismissal. Judicial Review 60 days from date Federal Court of receipt of DAB (Departmental Appeals Board) decision declination of review by DAB. When an initial claim submitted is denied, the first step of appeal is the redetermination. At that time, the supplier person supplying the infmation may appeal the decision. Subsequent denials advance the appeals process to Reconsideration, Hearing, Department Appeals Board, and Judicial Review-Federal court. The DME MACs have compiled lists of the most common errs related to denials in payment: Illegible documentation Biller err Incomplete CMNs Orders and documentation that do not substantiate the material submitted ICD-9 codes that are not specific Unsigned CMNs MD ders that do not agree with the therapy billed Lack of permanence in patient therapy Page 2 SITUATION F Pt. had 10% wt. loss in < 3 months SITUATION E Pt. had 10% wt. loss in < 3 months Serum Albumin is < 3.4 gm/dl No Pt. is taking maximum doses of prokinetic medication SITUATION D Pt. has complete mechanical small bowel obstruction Surgery is not an option Situation E Serum Albumin is < 3.4 gm/dl Pt. had 72 hour fecal fat test Fecal fat exceeds 50% of al/enteral intake on a diet > 50 gm fat/day Situation F Pt. has daily symptoms of N&V Pt. had diagnostic test that documents motility disturbance * Radioisotope study demonstrates that isotope fails to reach the rt. colon by 6 hrs. * X-ray study demonstrates that barium pellets fail to reach the rt. Colon by 6 hrs. No Situation G/H on page 3 Pt. is not acutely ill on any medication which would decrease bowel motility Patient meets Medicare coverage criteria f home TPN therapy under Situation D Patient meets Medicare coverage criteria f home TPN therapy under Situation E Patient meets Medicare coverage criteria f home TPN therapy under Situation F 22

Suppt Line August 2006 Volume 28 No. 4 Page 3 SITUATIONS G/H Pt. had 10% wt. loss in < 3 months AND Serum Albumin is < 3.4 gm/dl AND Altering the nutrient composition of an enteral diet will not maintain the patient s health status AND The patient's health status cannot be maintained by administering medications to treat the etiology of the malabsption Pt. has moderate abnmality such as: *72 o fecal fat study shows fecal fat is > 25% of al/enteral intake on a diet > 50 gm fat/day *Dx of malabsption with objective confirmation by methods other than 72 o fecal fat test (Sudan stain of stool, d-xylose, etc. *Gastroparesis demonstrated by study that shows the isotope, barium pellets failed to reach the rt. colon in 3-6 hr results manometric motility study was consistent with abnmal gastric emptying that was unresponsive to prokinetic medication *Small bowl motility disturbance which is unresponsive to prokinetic medication, demonstrated with a gastric to rt colon transit time between 3-6 hrs *Small bowel resection that left > 5 ft of small bowel beyond the ligament of Treitz *Sht bowel syndrome not as severe as Situation B *Mild to moderate exacerbation of regional enteritis enterocutaneous fistula *Partial mechanical small bowel obstruction where surgery is not an option Patient does not meet Medicare coverage criteria f home TPN therapy. Medical Recds document a failed Tube Trial Patient meets Medicare coverage criteria f home TPN therapy under Situations G/H Transposition of numerical digits when submitting claims electronically Therapies that do not meet Medicare coverage criteria When a denial is obtained from Medicare, it is imptant to ascertain the exact reason f denial and address the documentation and/ other needs based on why the claim was not paid. Medicare can provide a written reason f the denial of any service submitted. The amount of documentation required and the case presented must be based on crection of the material submitted. A clear case must be submitted to Medicare to show the appropriateness and need f payment of the services provided. Frank R. Wojtylak, RD/CDN, is a private consultant wking in the field of Medicare reimbursement and qualification. Resources Regulation and Guidance: http://www.cms.hhs.gov/home/regsguidance.asp FAQs: http://questions.cms.hhs.gov/cgibin/cmshhs.cfg/php/enduser/ std_alp.php?p_sid=615fowbi CMS Homepage: http://www.cms.hhs.gov/ Medicare Infmation: http://www.cms.hhs.gov/home/medicare.asp Medicare Appeals Infmation: http://www.cms.hhs.gov/mmcag/ Mailing List Resource: http://www.cms.hhs.gov/mlnproducts/downloads/mailinglists_factsheet.pdf 23