Get the answer to any of the following questions from the list below.
Are Abbott Nutrition products considered Over-the-Counter? Does the new 13-month capped rental change apply to enteral feeding pumps? What is an NPI (National Provider Identifier) code? What is a DIF form? When must providers be accredited? How is a feeding set (administration set) reimbursed? How is enteral nutrition billed to Medicare? What are the calories per can for the Metabolic formulas? Will Medicare cover a nutritional product if the patient is consuming it orally? Will private insurance plans cover Abbott Nutrition products? How do patients get a product if they have Medicaid and it is a covered benefit? Will the Abbott Nutrition Home Delivery program bill patients' insurance? Q: Are Abbott Nutrition products considered Over-the-Counter? A: Abbott Nutrition currently does not market any over the counter drugs. Most Abbott Nutrition products, but not all, are medical foods or infant formulas under US Food and Drug Administration regulations. A medical food is a food that is specially formulated to be consumed or administered enterally under the supervision of a physician and is intended only for the specific dietary management of a disease or condition for which distinctive nutritional requirements have been scientifically established. Abbott Nutrition medical food products are not drugs and therefore a prescription is not required by law to obtain them. However, many pharmacies and DME dealers do have policies that require a medical order to purchase some of our medical food products to assure they provide the appropriate medical food product for a given condition.
Q: Does the new 13-month capped rental change apply to enteral feeding pumps? A: The 13-month DME capped rental changes do not apply to enteral feeding pumps because they are covered under the prosthetic device benefit, not the DME benefit. We encourage you to call your DMERC, CMS, or Medicare Ombudsman if you have further questions.
Q: What is an NPI (National Provider Identifier) code? A: The Health Insurance Portability and Accountability Act (HIPAA) mandated that there be a standard unique health identifier for health care providers. The purpose of these provisions is to improve the efficiency and effectiveness of the electronic transmission of health information. On March 1, 2008, Medicare claims submitted by physicians and other practitioners, laboratories, ambulance company suppliers, DMEPOS suppliers and others that bill Medicare are required to include the new National Provider Identifier (NPI).
Q: What is a DIF form? A: Beginning October 1, 2006, a new form called a DIF (DME MAC Information Form) became available for suppliers to use in place of the enteral nutrition CMN (Certificate of Medical Necessity) when billing Medicare Part B. The DIF served the same purpose as the CMN with some variances. CMNs required a physician's signature and a narrative description of equipment and products. A DIF is completed and signed only by the supplier. When using the DIF, the physician's signature and narrative description, including patient-specific medical necessity information, is still required but can be obtained by the supplier via verbal and written orders. The suppliers are required to keep this information in their files. Suppliers are responsible for the accuracy of all patient information on the DIF.
Q: When must providers be accredited? A: The Centers for Medicare and Medicaid Services (CMS) announced that all Medicare Part B Durable Medical Equipment suppliers must be accredited by September 30, 2009. Suppliers who are not accredited by September 30, 2009 will not be able to bill Medicare for DMEPOS supplies, which include enteral nutrition supplies. This deadline applies only to existing Medicare suppliers. In the future, CMS will provide additional details and deadlines that will provide all of the necessary information for new suppliers who are interested in enrolling in the Medicare program and need to obtain accreditation. The accreditation requirement applies to suppliers who bill Medicare Part B under the DMEPOS benefit. Accreditation is not necessary for suppliers who are billing under a different program such as Medicare Part D.
Q: How is a feeding set (administration set) reimbursed? A: A feeding set is part of a daily supply kit. A daily supply kit by definition includes everything necessary to deliver enteral nutrition to a patient in a day. It consists of, at minimum, a container, tubing, tape, gloves, and a flushing syringe. There are three kinds of daily supply kits: pump, gravity, and syringe.
Q: How is enteral nutrition billed to Medicare? A: Enteral nutritional formula is billed in "units." A unit is defined as 100 Calories.
Calculation of units: Cal per day/100 = units per day
Example: 6 cans of Jevity
® 1 CAL/day x 250 Cal/can = 1500 Cal/day/100 = 15 units/day
Q: What are the calories per can for the Metabolic formulas? A: | Stock Code | Product | Calories/Can | Grams/Can |
00378
53328 | Calcilo XD®
Calcilo XD® | 2052
1924 | 400
375 |
| 51144 | Cyclinex®-1 | 2040 | 400 |
| 51146 | Cyclinex®-2 | 1760 | 400 |
| 51140 | Glutarex®-1 | 1920 | 400 |
| 51142 | Glutarex®-2 | 1640 | 400 |
| 51116 | Hominex®-1 | 1920 | 400 |
| 51118 | Hominex®-2 | 1640 | 400 |
| 51136 | I-Valex®-1 | 1920 | 400 |
| 51138 | I-Valex®-2 | 1640 | 400 |
| 51112 | Ketonex®-1 | 1920 | 400 |
| 51114 | Ketonex®-2 | 1640 | 400 |
| 51120 | PhenexTM-1 | 1920 | 400 |
55755
51122 | PhenexTM-2
Vanilla
Unflavored | 1640
1640 | 400
400 |
| 51148 | Pro-Phree® | 2040 | 400 |
| 51132 | Propimex®-1 | 1920 | 400 |
| 51134 | Propimex®-2 | 1640 | 400 |
| 50260 | ProViMin® | 468 | 150 |
| 00108 | RCF® | 311 | 384 mL |
| 51128 | Tyrex®-1 | 1920 | 400 |
| 51126 | Tyrex®-2 | 1640 | 400 |
*The product information provided above is accurate at time of publication; product labels should be referenced when calculating units for billing to ensure the most current information is being used case by case. Q: Will Medicare cover a nutritional product if the patient is consuming it orally? A: Medicare does not have a policy for coverage of orally consumed nutritional products. Medicare Part B has a coverage policy for medically necessary tube-fed nutritionals only.
Q: Will private insurance plans cover Abbott Nutrition products? A: Some insurance plans provide coverage for medical foods. Most often they are covered when administered through a feeding tube, used to treat inborn errors of metabolism and specialty products for infants and children. A few insurance plans may provide coverage for medical foods that are consumed orally under the supervision of a physician that are intended for the dietary management of a specific condition. Most often-specific medical necessity criteria apply. We encourage patients to contact their insurance company directly for specific coverage and policy information.
Q: How do patients get a product if they have Medicaid and it is a covered benefit? A: This process varies by state. Generally, if a patient's Medicaid policy provides coverage for nutritional products, patients can obtain a prescription from their health care professional. They can then take the prescription to a Medicaid provider, such as a durable medical equipment company or pharmacy to obtain the product. If the Medicaid provider offers this service, its staff can initiate the appropriate paperwork, provide the product and file a claim on the patient's behalf.
Q: Will the Abbott Nutrition Home Delivery program bill patients' insurance? A: Abbott Nutrition is a product manufacturer and not a healthcare provider. We cannot bill third party insurance, Medicare or Medicaid. Our Home Delivery program is a direct purchase consumer program set up for patients' convenience and can take Visa®, MasterCard®, or Discover®. Patients may also mail an order with a check or money order.
