Completion of the Elements of PEN CMN - Part 3

Enteral nutrient categories III through VI require additional medical justification for coverage. These categories represent formulas for special needs or use.

• Category III (code B4153): hydrolyzed protein/amino acids. These products contain a high nitrogen availability as a result of chemical treatment to reduce high molecular protein compounds into smaller molecules and amino acids that are easier to digest.

• Category IV (code B4154): defined formulas for special metabolic needs and conditions such as abnormal glucose tolerance, renal disease, liver disease, HIV, respiratory insufficiency, and malnutrition.

• Category V (code B4155): modular components


• Category VI (code B4156): standardized nutrients. These products contain low residue ingredients.

If the patient exhibits a problem with any particular formula in Nutrient Category I (HCPCS B4150) or II (HCPCS B4152), the physician must document the unfavorable events that resulted in prescribing a higher category formula.

Generally, daily enteral intake of 750 to 2,000 calories is considered sufficient to maintain body weight. Patients with medical complications may require an intake outside the range. The attending physician must document the reason for prescribing less than 750 calories per day or more than 2000 calories per day.

Enteral nutrition may be administered by syringe, gravity, or pump. The attending physician must specify the reason that necessitates the use of an enteral feeding pump. Some enteral patients may experience complications associated with syringe or gravity method of administration. Contractors provide coverage for enteral pumps if the medical necessity is documented by the attending physician on the CMN. Examples of circumstances that indicate the need for a pump include, but are not limited to:

• Aspiration or Dumping Syndrome;

• Severe diarrhea remedied by regulated feeding;

• Insulin-dependent diabetics who require a flow rate of less than 100cc's per hour for proper regulation of nutrients;

• Patients with congestive heart failure who require a pump to prevent circulatory overload; or


The DMERC reviews the claims to ensure that the equipment for which payment is claimed is consistent with that prescribed (e.g., expect a claim for an I.V. pole, if a pump is used).

5. Attending Physician's Signature and Identification - A handwritten, original signature and date must be on each certification. The form must be dated to show reasonable association to the dates of active PEN therapy. The full name, address, telephone number (including area code), and Unique Physician Identification Number (UPIN) allows the contractor to determine if the prescriber is authorized to order Medicare services and facilitate claims dependant.

1. PEN Supplier's Identification - The PEN supplier's name, address, telephone number, and PEN identification number must be on each certification. This information allows the contractor to determine if the supplier is authorized to provide PEN supplies and facilitate claims development.