Or. Admin. R. 410-148-0260 - Home Enteral Nutrition

(1) Codes that have PA indicated require prior authorization. Codes with BR indicated are covered by report.

(2) Enteral nutrition formula. Use B4150 through B4156 when billing for tube fed nutritional formulae. If the product dispensed is not shown in HCPCS description, select a category equivalent when billing the Division of Medical Assistance Programs (Division).

(3) Oral nutritional supplements:

(a) Prior authorization is required on all oral nutritional supplements;

(b) Oral nutritional supplements can be billed through the on-line point of sale pharmacy system, or by paper using the CMS 1500 claim form or the electronic 837P claim form. Use the product's NDC and HCPC code when billing the CMS 1500 or electronic 837P claim form;

(c) If the product dispensed is not shown in one of the listed categories, select a category that is equivalent when billing the Division;

(d) Oral nutritional supplements may be approved when the following criteria has been met:

(A) Clients age 6 and above:

(i) Must have a nutritional deficiency identified by one of the following:

(I) Recent low serum protein levels; or

(II) Recent registered dietician assessment shows sufficient caloric/protein intake is not obtainable through regular, liquefied or pureed foods;

(ii) The clinical exception to the requirements of (I) and (II) must meet the following:

(I) Prolonged history (i.e. years) of malnutrition, and diagnosis or symptoms of cachexia, and

(II) Client residence in home, nursing facility, or chronic home care facility, and

(III) Where (I) and (II) would be futile and invasive

(iii) Must have a recent unplanned weight loss of at least 10%, plus one of the following:

(I) Increased metabolic need resulting from severe trauma; or

(II) Malabsorption difficulties (e.g., short-gut syndrome, fistula, cystic fibrosis, renal dialysis); or

(III) Ongoing cancer treatment, advanced Acquired Immune Deficiency Syndrome (AIDS) or pulmonary insufficiency.

(iv) Weight loss criteria may be waived if body weight is being maintained by supplements due to patient's medical condition (e.g., renal failure, AIDS)

(B) Clients under age 6:

(i) Diagnosis of 'failure to thrive;

(ii) Must meet same criteria as above, with the exception of % of weight loss.

(4) Enteral nutrition equipment:

(a) All repair and maintenance is subject to rule 410-1480-0080;

(b) Procedure codes:

(A) S5036, Repair of infusion device (each 15 minutes = 1 unit) -- PA;

(B) B9998, Enteral nutrition infusion pump replacement parts will be reimbursed at provider's acquisition cost (including shipping and handling);

(C) B9000, Enteral nutrition infusion pump, without alarm -- rental (1 month = 1 unit) -- PA;

(D) B9002, Enteral nutrition infusion pump, with alarm -- rental (1 month = 1 unit) -- PA;

(E) E0776, IV pole -- purchase;

(F) E0776, modifier RR, IV pole -- rental (1 day = 1 unit);

(G) S9342, Enteral nutrition via pump (1 day = 1 unit) -- PA.

(5) Home infusion therapy:

(a) S9325, Home infusion, pain management (do not use with code S9326, S9327 or S9328) -- PA

(b) S9326, Home infusion, continuous pain management -- PA;

(c) S9327, Home infusion, intermittent pain management -- PA;

(d) S9328, Home infusion, implanted pump pain management -- PA.

(6) Not Otherwise Classified (NOC):

(a) B9998, NOC for enteral supplies;

(b) S9379, Home infusion therapy, NOC -- PA/BR.

Notes

Or. Admin. R. 410-148-0260

HR 26-1990, f. 8-31-90, cert. ef. 9-1-90; HR 26-1993, f. & cert. ef. 10-1-93; HR 3-1995, f. & cert. ef. 2-1-95; OMAP 7-1998, f. 2-27-98, cert. ef. 3-1-98; OMAP 29-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 46-2001, f. 9-24-01, cert. ef. 10-1-01, Renumbered from 410-121-0840; OMAP 22-2003, f. 3-26-03, cert. ef. 4-1-03; OMAP 63-2003, f. 9-5-03, cert. ef. 10-1-03; OMAP 15-2004, f. 3-11-04, cert. ef. 4-1-04; OMAP 52-2006, f. 12-28-06 cert. ef. 1-1-07; DMAP 23-2009, f. 6-12-09, cert. ef. 7-1-09

Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065