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EXHIBIT 15 - EXAMPLE OF INDICATIONS FOR USE AND REQUIREDJUSTIFICATION FOR REIMBURSEMENT OF A CATEGORY IV FORMULA (CONTINUED)Formula ICD-9 Indications/JustificationMagnacal ® Renal 584-584.9 Acute Renal FailureJustification:Must have increased BUN (>40) and Creatinine (>2.0)Serum electrolyte elevation (Na + , K + , PO4, MG ++ )Tolerates less than 50gm protein585 Chronic Renal FailureJustification:Must have increased BUN (>40) and Creatinine (>2.0)Serum electrolyte elevation (Na + , K + , PO4, MG ++ )Note: Another acceptable MJN formula for patients with renal failure is Deliver 2.0 ® .Magnacal ® Renal is a registered trademark of Sherwood Services AG.65
EXHIBIT 15 - EXAMPLE OF INDICATIONS FOR USE AND REQUIREDJUSTIFICATION FOR REIMBURSEMENT OF A CATEGORY III FORMULAFormula ICD-9 Indications/JustificationSubdue ® 043.3 Gastrointestinal DisordersSubdue Plus ®Justification:AIDS/HIV infection causing diarrhea or intestinal malabsorption; residentexhibited malabsorption/maldigestion with documented intolerance to asemi-synthetic intact formula as evidenced <strong>by</strong> diarrhea and steatorrhea555.0- Regional Enteritis/Crohn’s Disease555.9579.0 Short-Bowel Syndrome558.0- Other non-infectious gastoenteritis and colitis558.9579.8 Other specified intestine malabsorption579.9 Unspecified intestine malabsorption792.1 Fat in stoolJustification:➝➝➝➝Resident exhibits malabsorption/maldigestion with documented intolerance to asemi-synthetic intact formula as evidenced <strong>by</strong> diarrhea or steatorrhea; orResident has clinical or biochemical evidence of impaired gut function/gutcompromise, (i.e., positive xylose, lactulose or mannitol tests); orResident has a history of diarrhea or extensive GI pathology and clinicalanticipated malabsorption of a semi-synthetic intact formulaPancreatic Disease/Disorders277.0 Cystic Fibrosis577.0 Acute Pancreatitis577.1 Chronic Pancreatitis579.4 Pancreatic SteatorrheaJustification:Resident exhibits elevated serum amylase and/or lipase or abdominal pain whileusing a semi-synthetic intact formula; clinical indications suggest bowel rest isneeded to reduce pancreatic stimulationIn all cases, coverage should be confirmed with applicable DMERC.66
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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
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SECTION III - MEDICARE BILLING FOR
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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 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: EXHIBIT 15 - EXAMPLE OF INDICATIONS
Page 71 and 72: 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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