Medicare coverage, medical necessity, and supplies all weigh in.

Enteral nutrition is a method of delivering nutrients directly into the gastrointestinal (GI) tract when a patient cannot meet nutritional needs orally but still has a functioning digestive system. Unlike parenteral nutrition, which bypasses the GI tract entirely by delivering nutrients intravenously, enteral nutrition utilizes the absorptive capabilities of the gut. This approach is typically preferred because it maintains the physiological functions of the digestive system, reduces the risk of complications such as infections, and is generally more cost-effective.

Enteral feeding can be administered through various routes, including nasogastric tubes, gastrostomy, or jejunostomy feeding tubes. These methods employ different techniques such as syringe feeding, which delivers nutrition rapidly but may increase the risk of aspiration; gravity feeding, which uses a drip system; and infusion pumps, which regulate the feeding rate into the tube. While oral enteral nutrition is clinically used, Medicare does not cover oral administration or related supplies and equipment.

Patients requiring enteral nutrition often present with conditions such as head and neck cancers (particularly post-reconstructive surgery), severe dysphagia following cerebrovascular accidents, advanced neurodegenerative diseases like amyotrophic lateral sclerosis (ALS), inflammatory bowel diseases, short bowel syndrome, cystic fibrosis, chronic pancreatitis, and advanced liver disease.

Know How Medicare Covers Enteral Nutrition

Enteral nutrition is covered under Medicare’s prosthetic device benefit when specific criteria are met. The beneficiary must require enteral nutrition due to a permanent impairment, either involving the structures that allow food to reach the small bowel or the small bowel itself, which results in the inability to digest and absorb nutrients. However, the term “permanent” does not mean the condition is irreversible or lifelong. If the patient’s record, including the judgment of the treating provider, indicates that the impairment will “be of long and indefinite duration,” then this criterion is considered met. In addition, Medicare specifies that adequate nutrition must not be achieved through dietary modifications or oral supplementation alone. Medicare outlines specific coverage rules regarding nutrients, equipment, and supplies.

Then Understand Nutrient Coding

Semi-synthetic intact protein formulas and protein isolates, billed with either HCPCS Level II code B4150 (Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit) or B4152 (Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit), are appropriate for most patients.

In contrast, special enteral formulas, such as those described by B4153 (Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit) and B4162 (Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit), require detailed documentation explaining why standard formulas cannot meet the beneficiary’s metabolic needs. A simple diagnosis is insufficient to justify a specialty formula; supporting documentation must include failed attempts of standard formulas or metabolic abnormalities that require a specialty product.

Medicare does not cover the following items under enteral nutrition services:

• Food thickeners, coded to B4100 (Food thickener, administered orally, per ounce), baby food, and other blended grocery items
• Electrolyte-containing fluids, coded to B4102 (Enteral formula, for adults, used to replace fluids and electrolytes (e.g., clear liquids), 500 ml = 1 unit) and B4103 (Enteral formula, for pediatrics, used to replace fluids and electrolytes (e.g., clear liquids), 500 ml = 1 unit), as these are not intended for maintaining weight and strength
• Self-blended formulas, and
• Enteral formula additives, coded to B4104 (Additive for enteral formula (e.g., fiber), as the base enteral formula codes already include all nutrient components.

Familiarize Yourself With These Equipment and Supply Codes

An enteral pump, described by B9002 (Enteral nutrition infusion pump, any type), is covered only when justified by complications related to syringe or gravity feeding methods. Documentation must specify the clinical need for a pump such as reflux, aspiration risk, severe diarrhea, or administration rates requiring controlled delivery. In-line digestive enzyme cartridges, coded to B4105 (In-line cartridge containing digestive enzyme(s) for enteral feeding, each) are covered only for beneficiaries diagnosed with exocrine pancreatic insufficiency or other specified conditions.

Then Know These Coding and Billing Tips

As we alluded to above, HCPCS Level II B codes are used to report enteral nutrition services. These codes fall into three categories:

• Supplies and equipment (B4034-B4088)
• Formulas and additives (B4100-B4162)
• Infusion pumps and miscellaneous supplies (B9002-B9999)

Supply kit codes, such as B4035 (Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape), bundle all necessary supplies (e.g., syringes, bags, tubing, dressings) for one day of enteral nutrition administration. These bundled supplies cannot be billed separately, and only one unit of service per day is permitted.

Additionally, Medicare limits the frequency of feeding tube replacement. Coverage for nasogastric and stomach tubes (B4081-B4083) is limited to no more than three in a three-month period. For gastrostomy and jejunostomy tubes (B4087 and B4088), coverage is limited to one replacement every three months; additional replacements within the same time period are not covered.

For special nutrient enteral formulas (B4149, B4153, B4154, B4155, B4157, B4161, and B4162), the product must appear on the PDAC Product Classification List (PCL). If it is not listed, suppliers must seek guidance from PDAC to ensure correct coding.

Get a Handle on These Modifiers

Modifiers are essential for coding enteral nutrition. Modifier BA (Item furnished in conjunction with parenteral enteral nutrition (PEN) services), for example, should accompany code E0776 (IV pole) when an IV pole is used. And you’ll use modifier BO (Orally administered nutrition, not by feeding tube) for oral administration, though this is not covered by Medicare.

When coverage criteria are not met, suppliers must use Advance Beneficiary Notice (ABN) modifiers GA (Waiver of liability statement issued as required by payer policy, individual case), GY (Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for Non-Medicare insurers, is not a contract benefit), or GZ (Item or service expected to be denied as not reasonable and necessary) to communicate expected denials. Modifier KX (Requirements specified in the medical policy have been met) confirms that all criteria have been met and the documentation is available upon request. Codes billed without these modifiers will be rejected.

For enteral pumps, you must append additional modifiers, such as RR (Rental), NU (New Equipment), KH (DMEPOS item, initial claim, purchase or first month rental), and MS (Six month maintenance and servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warranty), as appropriate.

Calculate Formulas and Billing Units

Proper unit calculation is crucial. One unit equals 100 calories. To determine the correct number of units on the bill, divide the total ordered daily calories by 100 to get units per day (UPD). For example, 1,500 calories per day / 100 calories = 15 UPD. Then, multiply the UPD by the number of service days to obtain the total billable units. For example, 15 UPD x 30 days = 450 units. The result, 450, is the number of units that should be included in the claim.

And Adhere to these Additional Documentation and Recordkeeping Guidelines

According to a Medicare Fee-for-Service Supplemental Improper Payment Data 2023 report, insufficient documentation accounted for 52.8 per cent of improper payments for enteral nutrition, medical necessity (30.6 per cent), and 6 per cent of the cases did not have an actual document to support the services. As with other services, documentation is key when it comes to supporting rendered services.

Suppliers must have a signed Standard Written Order (SWO) before billing enteral services. For items requiring a Written Order Prior to Delivery (WOPD), this must be obtained before delivery. Additionally, suppliers must maintain Proof of Delivery (POD) documentation.

The treating practitioner’s documentation and the durable medical equipment supplier’s documentation must demonstrate the medical necessity for the ordered items. The medical record should include the beneficiary’s diagnosis, clinical course, prognosis, extent of functional limitations, and prior interventions. Documentation must also demonstrate that the impairment is expected to be of long and indefinite duration. For specialty formulas or enzyme cartridges, the documentation must detail the failure or unsuitability of standard formulas and provide clinical justification.

Resources:

PDAC
Enteral Nutrition - Policy Article A58833
Enteral Nutrition LCD L38955
MLN Enteral Nutrition
Noridian Medicare

Gabriel Aponte Moberg, MSHIA, RN, RHIA, CPC, COC, CDEI, CDEO, CIC, CPMA, CRC, CCC,
CHONC, CCS-P, CCS, CDIP, CCDS, CCDS-O, AAPC Approved Instructor
(A version of this article first appeared on the AAPC Knowledge Center blog)