Enteral nutrition may be administered by syringe, gravity, or pump. If a pump is ordered by the physician, there must be documentation accompanying the Certificate of Medical Necessity (CMN) to justify its use (for example, gravity feeding is not satisfactory due to reflux and/or aspiration or severe diarrhea). If the medical necessity of the pump is not documented, the pump will be denied as not medically necessary.[56]

The feeding supply kit must correspond to the method of administration indicated in the Certificate of Medical Necessity (CMN). If it does not correspond, payment for the billed code will be based on the allowance for the lesser of either the code specified on the CMN or the billed code. If a pump supply kit is ordered and the medical necessity of the pump is not documented, payment will be based on the allowance for the least costly medically appropriate alternative.

The codes for feeding supply kits include any and all supplies (other than the feeding tube itself), required for one day of formula administration. Individual items may differ from patient to patient and from day to day. Only one unit of service may

be billed for any one day. Units of service in excess of one per day will be denied as not separately payable. Claims for

more than one type of kit code delivered on the same date or provided on an ongoing basis will be denied as not medically necessary.

Payment for a catheter/tube anchoring device is considered included in the allowance for enteral feeding supply kits.

Also, Medicare considers more than three nasogastric tubes, or one gastrostomy/jejunostomy tube every three months to be rarely medically necessary.[57]

For a patient receiving enteral nutrition via tube feeding to be covered, they must have a permanent non-function or disease of the structures that normally permit food to reach the small bowel, or they must have a disease of the small bowel which impairs digestion and absorption of an oral diet.

The test of permanence must also be met (the condition is expected to be of at least 3 months duration). Enteral nutrition is not covered for patients with a functioning gastrointestinal tract, but is covered for reasons of anatomic obstruction (for instance, head or neck cancer or reconstructive surgery), or a motility disorder such as dysphagia.

Medicare allows for only one month's supply of enteral formula, equipment or supplies for one month's prospective billing.

Claims submitted retrospectively, however, may include multiple months, and the patient’s physician is expected to see the patient within 30 days of initial certification.