Change to enteral nutrition impacts claims payment

Andrea Stark
reimbursement consultant, Mira Vista

A new enforcement of quantity details on detailed written orders for enteral nutrition is manifesting in claim denials.

CGS recently updated the language on the enteral documentation checklist (as of Jan. 27, 2015) that mentions a new description for quantity on the detailed written order to be represented on a “per fill” basis. This is new terminology and a compliance expectation that CGS and other MACs are now beginning to enforce.

We have not seen these quantity errors in prior claims because the medical reviewers were using discretion to calculate proper quantities using other elements on the detailed written order. However, because there are so many variations and fluctuations with the prescription and how claims are billed, they are now requiring the orders to be more specific to avoid denial. The provider education departments are also increasing their discussion of this expectation. The MACs are interpreting this nuance to be a part of the quantity requirement of the LCD.

This enforcement has been hardest felt in Jurisdiction C, but other MACs are incorporating this into their education, as well. To avoid future denials, providers are encouraged to secure updated orders for nutrition that comply with the details of a per-fill quantity:

·      Quantity to be dispensed (Should correspond with the total amount of each item to be provided per refill. This information may be expressed as cans, bottles/bags, cases, or billing units [1 unit=100calories]).

Under this new guidance the contractors are expecting language to appear on detailed written orders along the lines of:

·      1200 calories per day X 30 days X 12 refills

·      120 units at 100 calories X 30 days X 12 refills

If the patient is on a formula that consists of 300 calories per can, the suitable example might read:

·      4 cans per day X 30 days X 12 refills.

If you provide enteral nutrition, we encourage you to connect directly with your POE (Provider Outreach & Education) department of your MAC to confirm their expectations as there may be slight nuances from DME MAC to DME MAC. As additional details become available on this topic, MiraVista will keep you informed.

Andrea Stark can be reached at