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March 16, 2012

Enteral Nutrition Webinar FAQs

On February 29, 2012, CGS held an Enteral Nutrition Documentation Webinar.  Attached are questions and responses generated during and after the webinar.

Enteral Specific

Q. Is an order from the treating physician justification enough to bill a specialty nutrient (such as Glucerna) or must the beneficiary try a B4150 formula before a specialty nutrient, especially for long-term diabetics?

A. An order from the treating physician only is not enough justification for Medicare to make payment for a specialty formula. 

The beneficiary’s medical records must document the condition requiring the special formula as opposed to a B4150 formula and the severity of the condition as shown by history, physical exam and diagnostic/laboratory studies.  The records must document a response of the medical condition to the B4150 in comparison to the response to the prescribed specialty formula.

When a comparison is not made, there must be a medical reason given for the absence of a comparison.  The explanation for the absence must be individualized based on each beneficiary’s condition and not a general statement such as a diagnosis. 

For beneficiaries that have been on a special nutrition for more than 5 years, a trial period is not required.

Q. Can the Medical Directors develop a “Dear Physician” letter for specialty enteral nutrition?

A. The DME MAC Medical Directors periodically evaluate the need for additional “Dear Physician” letters and the request to have one created specific to enteral nutrition has been submitted for consideration.  Although there is not currently a “Dear Physician” letter for specialty enteral nutrition, there are 2 general “Dear Physician” letters that may be used in the interim.  The general letters can be found on the CGS website.

Dear Physician- Documentation of Continued Medical Necessity
http://www.cgsmedicare.com/jc/pubs/news/2010/0310/cope11796.html

Dear Physician- General Documentation
http://www.cgsmedicare.com/jc/forms/pdf/jc_physician_documentation_request_letter.pdfPDF

Q. Where can suppliers find more information on specialty nutrition trial periods?

A. CGS published an article “Specialty Nutrients- Documentation” on March 19, 2008.  Revisions were made to this article on June 10, 2010. 

The most common requests in Jurisdiction C are for specialty diabetic (B4154) formulas.  If the DME MAC sends an additional documentation request letter for a specialty formula, the documentation should answer the following questions:

Q. Can you explain what non-function of GI tract due to anatomical impairment or motility disorder means?  Will a diagnosis or general statement in the medical record be sufficient?

A. Nutrition is covered under the prosthetic benefit as a replacement when the GI tract is not working properly.  There must be an obstruction or condition which prevents nutrient from reaching the stomach.  A detailed narrative description of the condition should be included in the medical records as opposed to a diagnosis code and/or general statement.

Documentation

Q. Is continuous use justified with the clinical course and the medical condition history of the beneficiary?

A. The clinical course and medical condition history will not address if a beneficiary continues to use the nutrition and supplies.  Continuous use documentation can be the beneficiary’s medical records or supplier records.  Any of the following documentation may serve as continuous use documentation:

Q. Can verbal dispensing orders be called in by the treating physician and/or staff of the physician’s office or nursing home?

A. Yes

Q. Can nursing staff at the physician’s office or nursing home sign written dispensing orders?

A. No, the nursing staff can call the supplier to place a verbal dispensing order however the treating physician should sign written orders.  

Billing

Q. When Medicare has been making payment on nutrition and after review of the medical records it is determined the guidelines are not met or the documentation is insufficient, how do suppliers execute an ABN?

A. An Advanced Beneficiary Notice (ABN) may be executed and applied to future claims.  ABNs must be given to the Medicare beneficiary before items are provided to be valid.  An ABN should be issued prior to dispensing an item expected to be disallowed for:

An ABN can remain in effect up to a year for an extended course of treatment with no other new events.  Once the beneficiary has signed the ABN, it may not be modified or revised.

The current version of the ABN is form CMS-R-131 (03/11). Beginning January 1, 2012 and forward, suppliers must use the new ABN CMS-R-131 (03/11).  The ABN form CMS-R-131 (03/11) can be found online at https://www.cms.gov/Medicare/Medicare-General-Information/BNI/indexExternal Website. Additional information on ABNs can be found on the Beneficiary Notice Initiative webpage at https://www.cms.gov/Medicare/Medicare-General-Information/BNI/indexExternal Websiteand in the Jurisdiction C Supplier Manual Chapter 3 at http://www.cgsmedicare.com/jc/pubs/supman/index.html.

Q. What are suppliers’ options when denials are issued through Medical Review pre-payment audits due to clinical course information not being present because of multiple nursing facility transfers or when the initial clinical course documentation is missing?

A. When sufficient medical necessity information is lacking in a beneficiary’s medical records, suppliers may execute an ABN to transfer the responsibility of payment to the beneficiary. 

Suppliers are required to maintain medical records that demonstrate beneficiaries meet Medicare guidelines for at least 7 years.  Medical records older than 7 years should not be requested by Medical Review.  If records are not available due to the need being established for longer than 7 years, all supporting records within the retention time frame should be provided.   

Q. If we know claims for nutrition will be denied by Medicare due to lack of initial clinical course/history documentation, how should we bill for denial so a secondary insurance may pay?

A. Claims may be billed with a narrative indicating the billing is for denial only.  In addition, for dates of service on or after July 1, 2011, contractors will automatically deny claim lines submitted with the GZ modifier.  The GZ modifier indicates that an Advance Beneficiary Notice (ABN) was not issued to the beneficiary and signifies that the provider expects denial due to a lack of medical necessity based on an informed knowledge of Medicare policy.  Claims will be denied with CO-50.

For a patient responsibility denial, an ABN must be issued to the beneficiary.

Proof of Delivery/Refill Request

Q. What is meant by “quantity of items remaining” on refill requests received over the telephone?

A. Refill request documentation must indicate the number of supplies the beneficiary has remaining for each HCPCS code that will be bill separately.  The quantity may be the number of days the beneficiary has remaining or the actual amounts they have remaining.

Q. We ship supplies to beneficiaries in nursing facilities.  Can someone in central supply who notices supplies are running low request refills on the beneficiary’s behalf or does it have to be someone involved in treatment? Also, can central supply sign the delivery documentation on the beneficiary’s behalf?

A. Central supply personal at a nursing home can request refills on behalf of Medicare beneficiaries.  The central supply staff can and often does sign for deliveries on behalf of beneficiaries.  In both instances, the relationship to the beneficiary should be documented. 

Q. When a shipping service is used and items ship from a distribution center, will the tracking information from the distribution center, but not from the carrier, be sufficient proof of delivery documentation?

A. Information from the distribution center only will not be sufficient proof of delivery.  The following must be provided for proof of delivery for shipped items without a return post-paid delivery invoice:

Shipping invoice from distributor:

Tracking slip from carrier:

A common reference number should link the invoice and tracking slip- this information may be entered by the supplier.

Q. Can refill requests be written in medical records or do we need to have a specific form for this information and is this information something we need documented every time our beneficiaries receives nutrition and supplies?

A. The refill request documentation can be a written request from the beneficiary/caregiver or a written record of a phone conversation between the supplier and the beneficiary/caregiver. DME suppliers should create a form to collect all of the necessary refill request information. Refill requests should be documented for each shipment and not automatically shipped without contacting the beneficiary/caregiver or contact being made with the supplier.

If the items are picked up from a storefront instead of shipped, a copy of the sales receipt is sufficient refill request documentation.

Q. We deliver supplies directly to beneficiaries on a monthly basis and document the number of cans of feeding and other supplies on a visit sheet.  Is this ok or do we still need to keep a refill request form? 

A. Your visit sheet can serve as the refill request documentation as long as all of the elements required to meet the refill documentation requirements are included on the sheet and gathered by the person delivering the supplies.  The refill request requirements are and should document:

For telephone refill requests:

For written refill requests:

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