Enteral Medicare Guidelines

All Medicare Enteral referrals must include the following documentation:

  • H & P, diagnosis specific to enteral indication, progress notes including supporting documentation of the criteria listed below, and a nutritional assessment.
  • Documentation that patientís condition and need for enteral therapy is of at least three (3) months duration.
  • Nutrients will be administered via a feeding tube.

All following criteria must be met for coverage of enteral therapy:

Documentation / Required Medicare Criteria:
  • Documentation of an anatomic defect of the alimentary tract that prohibits food from reaching the small bowel i.e., CT scans, x-rays, EGD, barium swallow, speech therapy consultation, OR reports. OR
  • Documentation of small bowel disease/motility disorder which impairs digestion and absorption of an oral diet i.e. small bowel/esophageal motility studies, UGI with SBFT, small bowl biopsy, gastric emptying study, barium swallow, speech therapy consultation, OR reports. OR
  • Documentation of a partial impairment which requires prolonged infusion of enteral nutrients to maintain nutritional status i.e., barium swallow, CT scans, x-rays, OR reports, speech therapy consultations, UGI with SBFT.

  • Additional documentation requirements:

    • If pump administration is required, documentation from the physician justifying use of the pump is required. Justification may include: feeding into the jejunum, need for controlled rate of infusion secondary to risk for fluid / volume overload.
    • Some enteral formulas require a letter of justification from the physician to substantiate medical necessity. Chartwell will notify you if a letter is required based on the formula ordered.