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Issue Number - Name
0015 - Enteral Nutrition Therapy
Review Type
Complex
Claim Type
DME Supplier
Region and State
RAC 5
All States
Date Approved
2017-05-08

Description

Medical Necessity and Coding review: Documentation will be reviewed to determine if the use enteral nutrition therapy meets Medicare coverage criteria.

Affected Codes

  • HCPCS: A5200, A9270, B4034, B4035, B4036, B4081, B4082, B4083, B4087, B4088, B4100, B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162.
  • Modifiers: BA, BO, EY

Applicable Policy References 

  • 42 Code of Federal Regulations, Sections 405.980 (b)&(c) and Section 405.986
  • CMS Pub. 100-03, Medicare National Coverage Determination Manual, Section 180.2 
  • CMS Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 110 and 120
  • CMS Pub. 100-04, Medicare Claims Processing Manual, Chapter 20, Section 30.7
  • CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 4, Section 4.26
  • CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Sections 5.2.3, 5.3, 5.7, 5.8, and 5.9
  • LCD, L11553, Effective date 10/1/1993, Retired 9/30/15
  • LCD, L33783, Effective date 10/01/15
  • LCD, L27214, Effective date 10/1/93 
  • Supplemental Policy Article Enteral Nutrition, A25512, Effective date 4/1/2005, Retired 9/30/15
  • Supplemental Policy Article Enteral Nutrition, A52493, Effective date 10/1/15
  • Supplemental Policy Article, A25229, Retired 9/30/2015