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EXHIBIT 15 - EXAMPLE OF INDICATIONS FOR USE AND REQUIREDJUSTIFICATION FOR REIMBURSEMENT OF A CATEGORY IV FORMULAFormula ICD-9 Indications/JustificationProtain XL ®Wound Management707.0- Chronic ulcer of skin707.9870- Open wound of head, neck or trunk879880- Open wound of upper limb887890- Open wound of lower limb897949.2- Second and third degree burns949.5Justification:Residents must exhibit an increased need for protein (i.e., = 1.2gm/kg body weight) andmicronutrients with moderate caloric needs in order to replete and/or maintainlean body mass; must present with Stage III or IV pressure ulcers; documentation forpressure ulcers must include site, size and stage262- Malnutrition263.8Justification:Resident must be malnourished as indicated <strong>by</strong> albumin ≤ 3.0 or unintentional weightloss > 10%; documentation must include serum albumin level and date drawn➝ Other diagnoses➝➝➝FracturesTraumaCancerDocumentation should include location of fracture, extent of trauma or type of cancer277.0 Cystic FibrosisNote: Another acceptable MJN formula for wound patients: Boost ® High Protein. Protain XL ® is a registered trademark of SherwoodServices, AG.In all cases, coverage should be confirmed with applicable DMERC.67
EXHIBIT 15 - EXAMPLE OF INDICATIONS FOR USE AND REQUIREDJUSTIFICATION FOR REIMBURSEMENT OF A CATEGORY IV FORMULA (CONTINUED)Formula ICD-9 Indications/JustificationTraumacal ®Sepsis/Infection038.0- Sepsis038.9041.9 Bacterial infection136.9 Infection, unspecified480-487 Pneumonia599.0 Urinary tract879.3,879.5 Abdominal wound infection997.3 Postoperative pneumonia998.5 Postoperative infection999.3 Complicating infectionJustification:May be primary or secondary diagnosis; the diagnosis of infection may also be coded as specificto the site; physician diagnosis and clinical evidence (such as fever, drainage from site ororganism isolated from blood, urine or sputum culture) should be included in the documentation490-496 COPD, ventilator dependent518.5 Pulmonary insufficiency following trauma/surgery518.81 Respiratory failure707.0-707.9 Chronic ulcer of the skin828-829 Multiple fracture854 Head injury949.2- Second or third degree burns949.5941.2- Major surgery946.5Justification:Must be a condition that requires = 1.2 times the resident’s caloric and protein needs; thisincludes hypermetabolic residents recovering from surgery, trauma or burns262-263.8 MalnutritionJustification:Resident must be malnourished as indicated <strong>by</strong> albumin = 3.0 or unintentional weightloss > 10%; documentation must include serum albumin level and date drawn➝➝➝➝Other diagnosesMajor traumaCancerHypermetabolismDocumentation should include extent of trauma and type of cancerNote: Another acceptable MJN formula for patients with hypermetabolism is Deliver ® 2.0; another acceptable MJN formula for patientswith respiratory failure is Respalor ® .In all cases, coverage should be confirmed with applicable DMERC.68
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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
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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
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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 and 68: EXHIBIT 15 - EXAMPLE OF INDICATIONS
Page 69: 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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