Documentation Needed for Home EN Coverage; Medicare Part B Fee-for-Service

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Information for Healthcare Professionals, Discharge Planners, Case Managers, and HMEs

A Medicare beneficiary receiving enteral nutrition (EN), or formula fed through a feeding tube, in the hospital and planning to go home on EN therapy will require documentation to help ensure home enteral therapy is covered by traditional Medicare after hospital discharge. Below are helpful resources to identify what is needed when planning for home EN coverage for a Medicare beneficiary.  

Steps to Follow

  1. 1
    Step 1: Identify the indication for home EN therapy.

    (Source: See 2021 EN Policy Article for list of ICD-10 codes) 

    • Note the conditions that qualify for coverage and what is not covered. 

  2. 2
    Step 2: Does the person require a feeding pump?

    A feeding pump must be justified. (Source: See new Enteral Local Coverage Determination 9/5/21)    

    • See conditions where a feeding pump is justified and will be covered.

  3. 3
    Step 3: Is a specialty formula needed?

  4. 4
    Step 4: Confirm all documentation requirements.

    Standard Written Order (SWO) – Must contain all the following: 

    1. Beneficiary’s name or Medicare Beneficiary Identifier (MBI)
        • Order Date
        • Description of the item(s)
        • Quantity to be dispensed if applicable
        • Treating Practitioner name or NPI
        • Treating Practitioners signature
        • SWO must be completed and signed prior to billing Medicare
    2. Beneficiary Authorization
    3. Proof of Delivery 
    4. DME MAC Information Form (DIF) 
    5. Advance Beneficiary Notice of Noncoverage (ABN) (when applicable)
    6. Information required for use of specific modifiers 
    7. Clinical documentation to support medical need and continued use of the item 

  5. 5
    Step 5: Identify delivery and shipment to the beneficiary.

    (Source: Standard Documentation Requirements for All Claims Submitted to DME MACs) 

    • Option 1: direct delivery to the beneficiary by the supplier. Note proof of delivery items to include.  
    • Option 2: shipping service. Note proof of delivery items to include.  
    • Option 3: Skilled Nursing Facility (SNF). Note documentation to include.

Patient & Caregiver Resources

Medicare Fee-for-Service
Medicare Advantage
Medicare Fee-for-Service vs. Medicare Advantage

Additional Resources

  1. 1
    Sources

    • CGS Administrators, LLC 
    • Centers for Medicare and Medicaid Services (CMS) 

  2. 2
    Websites

  3. 3
    CMS Documents/Guidance

    1. Enteral Nutrition Local Coverage Determination (9/5/21) 
    2. Enteral Nutrition Policy Article (9/5/21)