Medicare Qualification and Documentation Checklist for ...

1 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?

2 (Some possible report, unless clearly reports, unless clearly reasons: Unsafe? Hx aspiration spelled out in H&P or spelled out in H&P or pneumonia?; Tumor/radiation other medical other medical effects,/mucositis causing obvious severe Documentation Documentation difficulty swallowing - swallow study not warranted?). ICD-9 : Pump Justification (Check all that apply): Failure to tolerated gravity feedings due to: Other Information: Reflux Administration rate<100cc/hour Aspiration Blood Glucose fluctuation Severe Diarrhea Circulatory overload Dumping Syndrome Other Tips: The word temporary disqualifies the therapy For ongoing Qualification the MD or prescriber should document in the medical record yearly that the patient is tube fed. Request this Documentation when obtaining annual orders. Research has shown that if the patient does not receive formula (blenderizes their own) Medicare states it will not pay. ( Medicare WILL pay for supplies in instances where the formula is being donated).

3 Other Notes/Comments: _____. _____. FINISHED, UNLESS A SPECIALTY FORMULA ORDERED GO TO NEXT PAGE. For Internal Use Only Requirements for Specialty Formulas: (B4149, B4153, B4154, B4155). Please Check Formula Types of Formula Applicable Diagnosis/Conditions Laboratory Results/ Other Doc. One Category Required B4149 Severe Allergies or intolerances documented in the medical record B4153 Peptide or AA based Conditions of the GI tract which affect Formula digestion and absorption (disease states, post-surgery, metabolic stress). documented in the medical record B4154 Diabetic Diabetes Mellitus Uncontrolled blood sugar (glucose) Medication list for DM (insulin and/or oral meds), if prescribed Renal (Nepro) ESRD, Stage 5 Hemodialysis Elevated creatinine dependent Other Renal Diagnosis Elevated creatinine Pulmonary A Pulmonary Diagnosis, COPD. Hepatic Hepatic Failure diagnosis Elevated ammonia, liver enzymes B4155 Modulars Juven, Diagnosis and Documentation Diagnosis and MCT Oil, Microlipid, supporting modular, requires Documentation supporting Polycose, Resource additional protein for wound healing modular, requires Arginaid, Resource additional protein for wound Beneprotein, healing Resource Glutasolve Additional Documentation Requirements: Has a standard formula been tried and is it evident in the medical record?

4 If not, will one be tried in the medical facility or at home? *Reimbursement may be compromised if standard is not tried If not, is there support in the medical record that the MD has documented, indicatinga medical reason that a standard formula cannot be used? The following are some reasons that the MD might document the need for the Specialized formula without first trying a standard formula: B4149 Patient has severe allergies B4153 Patient has severe malabsorption weaning from TPN. B4154 - (Diabetic, Renal, Pulmonary, Hepatic May be harmful to patient due to the severity of medical condition). Other Notes/Comments: _____. For Internal Use Only List of Diagnosis covered by Medicare Part B found in: PRACTICAL GASTROENTEROLOGY MAY 2013 15. See Abbott Medicare Enteral Reimbursement Manual 9th Edition for additional covered diagnosis codes, and for a comprehensive reimbursement reference Dysphagia ( ) Due to Neurological Disorders, including: (Dysphagia is fine to use).

5 CVA ( ). Parkinson's disease ( ). Multiple Sclerosis (340). Amyotrophic Lateral Sclerosis ( ). Anoxic Brain Damage ( ). Coma ( ). Cerebral Palsy ( ). Subdural hematoma ( ). Alzheimer's disease ( ). Late effects of cerebrovascular disease, dysphagia ( ). Functional or Structural Issues, which may prevent food from reaching the small bowel, includes: Dysphagia, pharyngoesophageal phase ( ). Neoplasm of Esophagus (150), Larynx (161), and Tongue ( ). Esophageal obstruction secondary to cancer or stricture ( ). Gastric Cancer ( ), Gastric outlet obstruction ( ). Dumping Syndrome ( ). Gastroparesis ( ). Intestinal Disorders, including: Other Functional Disorders of Intestine ( ). Bowel Obstruction or Stricture ( ). Intestinal Cancer ( ). Malabsorptive Disorders, including: Malabsorption, unspecified ( ). Crohn's Disease ( ). Chronic Pancreatitis ( ). Bowel Ischemia ( ). Cystic Fibrosis ( ). GI Fistulas, including: Tracheo-esophageal fistula ( ).

6 Intestinal fistula ( ). Diagnoses NOT Covered by Medicare (Unless occur along with anatomic, motility or disease diagnosis as listed above). Psychological disorders End stage disease with anorexia or nausea Failure to thrive Dementia Dehydration Poor appetite, etc. Alzheimer's disease memory issue forgetting to eat - Does qualify if having difficulty swallowing. Dysphasia Aphasia