Termination of Enteral Nutrition Local Coverage Determination & Related Policy Article with Correct Coding and Billing – November 12, 2020

Due to the gradual development of the enteral nutrition clinical paradigms, the Durable Medical Equipment (DME) Medicare Administrative Contractors (MACs) have made the decision to retire the Enteral Nutrition Local Coverage Determinations (LCDs) along with a related Policy Article. MACs are able to revise or retire their LCD’s at their own discretion, at any time as stated in the CMS Program Integrity Manual, Chapter 13, Section 13.3, (CMS Pub. 100-08). 

Any claims for Enteral Nutrition with dates of service on or after November 12, 2020 will no longer be subject to the LCD (L33783) and Policy Article (A52493). Instead, providers and suppliers should refer to the CMS National Coverage Determinations (NCD) Manual (CMS Pub. 100-03) Chapter 1, Section 180.2 – Enteral and Parenteral Nutritional Therapy – for additional information about the coverage criteria. Any claims with dates prior to November 12, 2020 are still subject to the LCD and related Policy Article. 

Enteral nutrition coverage is included under the Prosthetic Device benefit (Social Security Act § 1861(s)(8)). For claims with service dates on or after November 12, 2020 the beneficiary’s nutrition must meet the reasonable and necessary requirements from CMS NCD 180.2 for reimbursement eligibility. Any products that are administered orally or any comparable supplies will not be covered. If the beneficiary’s nutrition requirements are satisfied then medically necessary nutrients, administrative supplies, and equipment will be covered.

For a detailed list of exact coverage and billing requirements, please read the DME MAC article “Enteral Nutrition – Correct Coding and Billing” https://med.noridianmedicare.com/web/jadme/policies/dmd-articles/2020/enteral-nutrition-correct-coding-and-billing  

Medicare Coverage Database for Enteral LCD https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33783&ContrID=140 

Noridian “Enteral Nutrition – Correct Coding and Billing” article https://www.cgsmedicare.com/jb/pubs/news/2020/10/cope19137.html