Enteral Nutrition

Affected Providers

Treating practitioners and DME suppliers who bill for enteral nutrition.

HCPCS & CPT Codes

Local Coverage Determination (LCD): Enteral Nutrition (L38955) has the current HCPCS and CPT codes.

Background

According to the 2024 Medicare Fee-for-Service Supplemental Improper Payment Data, the improper payment rate for enteral nutrition is 23.8%, with a projected improper payment amount of $31.1 million.

We cover enteral nutrition under the prosthetic device benefit. You must meet reasonable and necessary requirements. We outline other policy requirements in Article: Enteral Nutrition (A58833) and LCD L38955.

Denial Reasons

Insufficient documentation accounted for 48.8% of improper payments for enteral nutrition during the 2024 reporting period, while medical necessity (27.6%) and other errors (23.6%) also caused improper payments. “Other” errors include duplicate payment, non-covered or unallowable service, or ineligible Medicare patient errors.

Preventing Denials

We pay no more than 1 month’s supply of enteral nutrients at any 1 time. Claims that involve a pump must have enough medical documentation to show the pump is reasonable and necessary (for example, gravity feeding isn’t satisfactory due to reflux and aspiration, severe diarrhea, dumping syndrome, administration rate less than 100 ml/hr, blood glucose fluctuations, circulatory overload, or gastrostomy or jejunostomy tube for feeding). If you don’t document the medical necessity of the pump, we deny it as not reasonable and necessary.

Refill Requirements

For DMEPOS items and supplies provided on a recurring basis, base your billing on prospective, not retrospective use.

Documentation Requirements

To justify payment, you must meet specific requirements when ordering DMEPOS.