Scheduling and Documenting Certifications and Recertifications of Medical Necessity for PEN

A certification for PEN therapy must accompany the initial claim submitted. The initial certification is valid for six months. Contractors establish the schedule on a case-by-case basis for recertifying the need for PEN therapy. A change in prescription for a beneficiary past the initial certification period does not restart the certification process.

A period of medical necessity ends when PEN services are not medically required for 2 consecutive months. The entire certification process, if required, begins after 2 consecutive months have elapsed.

A revised certification or a change in prescription may impact on the payment levels of PEN services. A revised certification is appropriate when there is a change:

• In the treating physician's orders in the category of nutrients and/or calories prescribed;

• By more than one liter in the daily volume of parenteral solutions;

• From home-mix to pre-mix or pre-mix to home-mix parenteral solutions;

• From enteral to parenteral or parenteral to enteral therapy; or

• In the method of infusion (e.g., from gravity-fed to pump-fed).