Transcription of Medicare Qualification and Documentation Checklist for ...
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Medicare Qualification and Documentation Checklist for ...
For Internal Use Only Medicare Enteral Tool Medicare Qualification and Documentation Checklist for Enteral Patients Date:_____ Patient Name:_____. Contact Name:_____ Contact Phone Number:_____. _____Orders/Script/Detailed Written Order (DWO) (Prefer to gather the following information upfront but, can be obtained at denial - MD must document the reason for prescribing if < than 750 calories/day or > than 2000) Ex. patient cannot maintain weight or health unless these calories provided as tube feeding . _____Documented Length of Need (90 days or greater, if LIFETIME please indicate). Referrals must qualify for tube feeding regardless of formula type for one of the following 3 conditions. Check the diagnosis that applies for this patient and provide the necessary Documentation . Indicate the appropriate ICD-9. Diagnosis: _____Dysphagia (other GI motility disorders) _____Obstruction _____Malabsorption Documents H&P or other medical record notes H&P or other medical H&P or other medical Required: describing condition (diagnosis), along with record notes describing record notes describing the following: condition (diagnosis), condition (diagnosis), along with the along with the following: following: Copy of swallow study, or if one has not or Test results and/or Test results and/or will not be done why?
Renal (Nepro) ESRD, Stage 5 Hemodialysis dependent Elevated creatinine Other Renal Diagnosis Elevated creatinine Pulmonary A Pulmonary Diagnosis, i.e. COPD
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