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EXHIBIT 3 - SAMPLE MDS FORM (CONTINUED)35
36EXHIBIT 3 - SAMPLE MDS FORM (CONTINUED)
Page 2 and 3: Enteral ProductReimbursement Guidef
Page 4 and 5: PREFACEThe purpose of this manual i
Page 7 and 8: LIST OF EXHIBITSExhibit 1 - RUG III
Page 9 and 10: SECTION II - TYPES OF PAYERSThere a
Page 11 and 12: Concurrent ReviewConcurrent review
Page 13 and 14: SECTION III - MEDICARE BILLING FOR
Page 15 and 16: 12EXHIBIT 1 - RUG III URBAN RATES
Page 17 and 18: The following services are either i
Page 19 and 20: 16EXHIBIT 3 - SAMPLE MDS FORM (CONT
Page 37: 34EXHIBIT 3 - SAMPLE MDS FORM (CONT
Page 41 and 42: 38EXHIBIT 4 - SAMPLE UB-92 FORM
Page 43 and 44: SECTION IV - SNF GUIDELINES FOR BIL
Page 45 and 46: SECTION V - ENTERAL BILLING FOR PAR
Page 47 and 48: ENTERAL PRODUCT COVERAGEEnteral pro
Page 49 and 50: 46EXHIBIT 6 - SAMPLE HCFA-1500 CLAI
Page 51 and 52: Enteral NutritionEnteral nutrition
Page 53 and 54: EXHIBIT 8 - MEDICARE APPROVED MEDIC
Page 55 and 56: EXHIBIT 9 - ENTERAL THERAPY DIAGNOS
Page 57 and 58: MEDICARE DOCUMENTATIONSpecial docum
Page 59 and 60: 56EXHIBIT 10 - SAMPLE CMN (CONTINUE
Page 61 and 62: CMN GUIDELINESThe following are gui
Page 63 and 64: ❏❏❏➝Conversation notes betw
Page 65 and 66: EXHIBIT 13 - DIAGNOSES GENERALLY AC
Page 67 and 68: EXHIBIT 15 - EXAMPLE OF INDICATIONS
Page 73 and 74: EXHIBIT 16 - ENTERAL PRODUCTS REFER
Page 75 and 76: Method 2 - AWP + Service ChargeMore
Page 77 and 78: Once the number is obtained, the pr
Page 79: NOTES

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