Benefit Criteria will Change for CCP Nutritional Products

Transcription

1 Benefit Criteria will Change for CCP Nutritional Products Information posted August 6, 2010 Nutritional products, including enteral formulas and food thickener, are a benefit of the Comprehensive Care Program (CCP). Enteral nutritional products (procedure codes B4103, B4104, and B4149) are a benefit of CCP in the home setting when they are prior-authorized for home health durable medical equipment (DME) and DME medical supplier providers. Nutritional products may be reimbursed with the following procedure codes: Procedure Codes B4100 B4103 B4104 B4149 B4150 B4152 B4153 B4154 B4155 B4157 B4158 B4159 B4160 B4161 B4162 Enteral nutrition supplies and equipment may be reimbursed with the following procedure codes and limitations: Procedure Codes Limitations A per month A per month B4034 Up to 31 per month B4035 Up to 31 per month B4036 Up to 31 per month B4081 As needed B4082 As needed B4083 As needed B per rolling year B per rolling year B purchase every 5 years; 1-month rental B purchase every 5 years; 1-month rental B9998* As needed* B9998 with modifier U1 4 per month B9998 with modifier U2 2 per rolling year B9998 with modifier U3 4 per month B9998 with modifier U5 4 per month T1999* As needed* If procedure code T1999 is used for a needleless syringe, the allowed amount is eight per month.

2 * Appropriate limitations for miscellaneous procedure codes B9998 and T1999 are determined on a case-by-case basis through prior authorization. Specific items may be requested using procedure code B9998 and the modifiers outlined in the table above. A backpack or carrying case for a portable enteral feeding pump may be a benefit of CCP, using procedure code B9998, if it is medically necessary and prior-authorized. Clients for whom nutritional products are being requested may benefit from nutritional counseling. Nutritional counseling is a benefit of CCP if it is provided to treat, prevent, or minimize the effects of illness, injury, or other impairment. Providers can refer to the 2010 Texas Medicaid Provider Procedures Manual, Children s Services Handbook, Section 3.6 Medical Nutrition Counseling Services (CCP) on page CH-54 for information about nutritional counseling. Prior Authorization Requirements Prior authorization for nutritional products is not required for a client who meets at least one of the following criteria: Receive all or part of their nutritional intake through a tube. Have a metabolic disorder that has been documented with one of the following diagnosis codes: Diagnosis Codes V441 V444 Prior authorization is required for nutritional products that are provided through CCP to clients who do not meet the criteria above and for all related supplies and equipment.

3 A completed CCP Prior Authorization Request Form that prescribes the DME and/or supplies must be signed and dated by a prescribing physician who was familiar with the client before making the authorization request. All signatures must be current, unaltered, original, and handwritten. Computerized or stamped signatures will not be accepted. The completed CCP Prior Authorization Request Form must include the procedure codes and numerical quantities for the services requested. A copy of the completed, signed, and dated CCP Prior Authorization Form must be maintained by the prescribing physician in the client s medical record. To complete the prior authorization process by paper, the provider must fax or mail the completed CCP Prior Authorization Form to the CCP Prior Authorization unit and retain a copy of the signed and dated CCP form in the client s medical record at the provider s place of business. To complete the prior authorization process electronically, the provider must complete the prior authorization requirements through any approved electronic methods and retain a copy of the signed and dated CCP Prior Authorization Request form in the client s medical record at the provider s place of business. Requests for prior authorization must include the following documentation: Accurate diagnostic information pertaining to the underlying diagnosis/condition that resulted in the requirement for a nutritional product, as well as any other medical diagnoses/conditions, including: o The client s overall health status. o Height and weight. o Growth history and/or growth charts. o Why the client cannot be maintained on an age-appropriate diet. o Other formulas tried and why they did not meet the client s needs. Diagnosis/condition (including the appropriate International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code). The goals and timelines on the medical plan of care. Total caloric intake prescribed by the physician. Acknowledgement that the client has a feeding tube in place. Related supplies and equipment for clients who require nutritional products may be considered for prior authorization when the criteria for nutritional products are met and medical necessity is included for each item requested. Prior authorization may be given for up to 12 months. Prior authorization may be recertified with documentation that supports the ongoing medical necessity of the requested nutritional products. A retrospective review may be performed to ensure that the documentation included in the client s medical record supports the medical necessity of the requested service. Nutritional Products Requests for prior authorization, when required, must include the necessary product information.

4 Enteral formulas consisting of semi-synthetic intact protein/protein isolates (procedure codes B4150 and B4152) are appropriate for the majority of clients requiring enteral nutrition. Special enteral formula and/or additives (procedure code B4104) may be considered for prior authorization with supporting documentation submitted by the client s physician indicating the client s medical needs for these special enteral formulas. Special enteral formula may be reimbursed with the following procedure codes: Procedure Codes B4149 B4153 B4154 B4155 B4157 B4161 B4162 Food thickener may be considered for clients with a swallowing disorder. Prior authorization of nutritional pudding products may be considered for children who have a documented oropharyngeal motor dysfunction and receive greater than 50 percent of their daily caloric intake from a nutritional pudding product. Requests for electrolyte replacement products, such as Pedialyte or Oralyte, require documentation of medical necessity, including: The underlying acute or chronic medical diagnoses or conditions that indicate the need to replace fluid and electrolyte losses. The presence of mild to moderate dehydration due to the persistent mild to moderate diarrhea or vomiting. Electrolyte replacement products are not indicated for clients with: Intractable vomiting Adynamic ileus Intestinal obstruction or perforated bowel Anuria, oliguria, or impaired homeostatic mechanism Severe, continuing diarrhea, when intended for use as the sole therapy Nasogastric, Gastrostomy, or Jejunostomy Feeding Tubes Feeding tubes require prior authorization. The limitations for feeding tubes are outlined in the limitations table above. Additional feeding tubes may be prior authorized if the submitted documentation supports medical necessity, such as documentation of an infection at the gastrostomy site, leakage, or occlusion. Enteral Feeding Pumps Enteral feeding pumps, with and without alarms, require prior authorization. The prior authorization of the lease or purchase of enteral feeding pumps may be considered with documentation of medical necessity that indicates that the client meets the following criteria: Gravity or syringe feedings are not medically indicated. The client requires an administration rate of less than 100 ml/hr. The client requires night-time feedings.

5 The client has one of the following medical conditions (this list is not all-inclusive): o Reflux and/or aspiration. o Severe diarrhea. o Dumping syndrome. o Blood glucose fluctuations. o Circulatory overload. Enteral Supplies Enteral supplies, except for irrigation syringes within the allowable limits, require prior authorization. Additional enteral feeding supply kits beyond the stated benefit limitation may be considered for prior authorization on a case-by-case basis with documentation of medical necessity. Procedure code B4034 will not be prior authorized for use in place of procedure code A4322 for irrigation syringes if they are not part of a bolus administration kit. Gravity bags and pump nutritional containers are included in the feeding supply kits and will not be prior authorized separately. Specific items may be considered for prior authorization using miscellaneous procedure code B9998 and modifier U1, U2, U3, or U5. Requests for a backpack or carrying case or for a portable enteral feeding pump will be considered for prior authorization for purchase only, under miscellaneous code B9998, for clients who meet all of the following medical necessity criteria: The client requires enteral feedings that last more than eight continuous hours, or feeding intervals that are greater than the time that the client must be away from home to: o Attend school or work. o Participate in extensive, physician-ordered outpatient therapies. o Attend frequent, multiple medical appointments. The client is ambulatory or uses a wheelchair that will not support the use of a portable pump by other means, such as an intravenous (IV) pole. The portable enteral feeding pump is client-owned. Procedure codes B4103, B4104, and B4149 will be denied when billed by any provider on the same day as procedure code B-651, B-652, B-655, or B-656. Non-Covered Services CCP does not cover: Nutritional products that are traditionally used for infant feeding. Nutritional products for the primary diagnosis of failure to thrive, failure to gain weight, or lack of growth. The underlying cause of failure to thrive, gain weight, and lack of growth is required.

6 Nutritional bars. Nutritional products for clients who could be sustained on an age-appropriate diet.