Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider." It is expected that the patient's medical records will reflect the need for the care provided. The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.

An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request Items billed before a signed and dated order has been received by the supplier must be submitted with an EY modifier added to each affected HCPCS code.

A DME Information Form (DIF) which has been completed, signed, and dated by the supplier, must be kept on file by the supplier and made available on request. The DIF for Parenteral Nutrition is CMS Form 10126. The initial claim must include an electronic copy of the DIF.

Information describing the medical justification for parenteral nutrition must be available upon request. This information shall describe which criterion (A-H) in Non-Medical Necessity Coverage and Payment Rules in the related Policy Article serves as the basis for coverage. This information is generally recorded in the patient's medical record. Some sources, not all-inclusive, are described below:

• For situations A-D, copies of the operative report and/or hospital discharge summary and/or x-ray reports and/or physician letter, which demonstrate the condition and the necessity for parenteral therapy.
  
  
• For situations E and H (when appropriate), results of the fecal fat test and dates of the test.
  
  
• For situations F, and H (when appropriate), copy of the report of the small bowel motility study and a list of medications that the patient was on at the time of the test.
  
  
• For situations E-H, results of serum albumin and date of test (within 1 week prior to initiation of parenteral nutrition, PN) and a copy of a nutritional assessment by a physician, dietitian or other qualified professional within 1 week prior to initiation of PN, to include the following information:
  
  
  1. Current weight with date and weight 1-3 mo. prior to initiation of PN;
     
     
  2. Estimated daily calorie intake during the prior month and by what route (e.g., oral, tube);
     
     
  3. Statement of whether there were caloric losses from vomiting or diarrhea and whether these estimated losses are reflected in the calorie count;
     
     
  4. Description of any dietary modifications made or supplements tried during the prior month (e.g., low fat, extra medium chain triglycerides, etc.);


• For situations described in H, a statement from the physician, copies of objective studies, and excerpts of the medical record giving the following information:
  
  
  1. Specific etiology for the gastroparesis, small bowel dysmotility, or malabsorption;
     
     
  2. A detailed description of the trial of tube enteral nutrition including the beginning and ending dates of the trial, duration of time that the tube was in place, the type and size of tube, the location of tip of the tube, the name of the enteral nutrient, the quantity, concentration, and rate of administration, and the results;
     
     
  3. A copy of the x-ray report or procedure report documenting placement of the tube in the jejunum;
     
     
  4. Prokinetic medications used, dosage, and dates of use;
     
     
  5. Nondietary treatment given during prior month directed at etiology of malabsorption (e.g., antibiotic for bacterial overgrowth);
     
     
  6. Any medications used that might impair GI tolerance to enteral feedings (e.g., anticholinergics, opiates, tricyclics, phenothiazines, etc.) or that might interfere with test results (e.g., mineral oil, etc.) and a statement explaining the need for these medications.

1. Nutrients billed with a different code are ordered, or


2. The number of days per week administered is changed.