DEPARTMENT OF HEALTH & HUMAN SERVICES 	 Office of Inspector General 
Washington, D,C. 20201 
JUN 2120ilD 
TO: 	 Marilyn Tavenner 
Acting Administrator and Chief Operating Officer 
Centers for Medicare & Medicaid Services 
FROM:  Stuart Wright 
Deputy Inspector General 
for Evaluation and Inspections 
SUBJECT: 	 Memorandum Report:  Medicare Part B Services During Non-Part A Nursing 
Home Stays:  Enteral Nutrition Therapy, OEI-06-07-00090 
This memorandum report presents the results of a medical record review to determine the extent to 
which Medicare Part B allowed inappropriate payments for enteral nutrition therapy (ENT) claims 
during non-Part A I nursing home2 stays in 2006.  We used resident assessment data from the 
Minimum Data Set (MDS) to identify all nursing home stays nationwide during 2006 and 
contracted with physicians specializing in gastroenterology and professional coders to conduct 
medical record reviews for a sample of Part BENT claims. 
We found that 21 percent ofthese ENT service claims were inappropriate (5 percent) or 
inadequately documented (16 percent).  These errors resulted in an estimated $39 million in 
inappropriate Part B payments among the $284 million allowed for all ENT claims during 
non-Part A nursing home stays in 2006.  Claims for pumps and pump supply kits represented 
70 percent of the inadequately documented sampled services. 
We also found that 13 percent ofthe allowed ENT claims associated with pumps were 
questionable.  Although these claims met Medicare contractor payment and coverage guidelines,3 
the residents' medical records did not document a medical condition (e.g., diabetes, risk of 
aspiration, or fluctuating glucose levels) that justified the need for the more expensive pump 
delivery method over the gravity method, which could provide for a slow rate.  Currently, 
Medicare contractor payment and coverage guidelines do not require the documentation of a 
I Nursing home stays not paid by Medicare Part A (Part A) constitute lion-Part A stays.  Part A covers posthospital skilled nursing facility (SNF) 

care to eligible beneficiaries for up to 100 days in SNFs during which.Part A will pay for ENT services as part of the nursing home's daily rate, 

After the 100 days or if the beneficiary does not qualify for a Part A stay, Medicare Part 13 (Part B) may provide coverage for ENT services. 

Non-Part A stays occur ill Medicare-certified SNFs, Medicaid-certified nursing facilities (NF), and dually certified SNF/NFs. 

2 For purposes of this evaluation, the term "nursing home" is generic for any nursing home regardless of primary payer (e.g., Medicare, 

Medicaid, or private resources), 

3 Medicare contractor payment and coverage guidelines allow payment for pump delivery methods based on the need for a slow delivery rate of 

less than 100 millimeters per hour. 

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medical condition specifically justifying pump use over the gravity method when a slow rate of 
administration is indicated.  
BACKGROUND    
The ENT services involve the provision of liquid nutrients directly to the digestive tract of a patient 
by threading a feeding tube through the nose or through an incision in the small intestine or 
stomach.  Enteral nutrients, supplies, and equipment are assigned procedure codes from the 
Healthcare Common Procedure Coding System (HCPCS).4  Of the $284 million that Medicare  
Part B allowed for ENT services during non-Part A stays in 2006 (more than 1.4 million claims), 
nearly half of the allowed amount was for nutrients ($142 million) and the remaining half was for 
enteral supplies and equipment ($142 million).   
Enteral nutrients.  A wide range of enteral nutrients exists to meet various health care needs, 
including special formulas for patients with pulmonary or metabolic diseases.  Two HCPCS 
codes, B4150 and B4154, accounted for nearly 83 percent of the allowed charges ($118 million 
of $142 million).  HCPCS code B4150 represents the most frequently used nutrient and 
accounted for 37 percent of the allowed charges; HCPCS code B4154 covers a more expensive 
class of nutrients for patients with special metabolic needs (e.g., diabetes) and accounted for 
nearly 46 percent of the allowed charges.  Enteral nutrients are billed and reimbursed by units, 
defined by Medicare as 100 calories.5  For example, if a patient is prescribed 2,000 calories of 
enteral nutrients per day, Medicare reimbursement is based on 20 units of nutrients per day 
(2,000  100).   
Enteral supplies and equipment.  Enteral supplies and equipment are used to administer the 
required nutrients.  Excluding any additional supplies, patients can receive enteral nutrients using 
three primary feeding supply kits:  (1) a syringe (the least expensive kit at $6.12 per day),  
(2) gravity ($8.00 per day), or (3) a pump (the most expensive kit and most frequently used method 
at $11.66 per day).  Taken together, the cost for 2,000 calories of the most frequently utilized 
standard enteral nutrient (B4150 at $0.67 per unit) and delivery method per day would be  
$19.52 for the syringe delivery method, $21.40 for the gravity method, and $25.06 for the pump 
delivery method.   
Medicare Part B covers ENT under Medicares prosthetic device benefit during non-Part A stays in 
SNFs, NFs, and dually certified SNF/NFs.  The prosthetic device benefit includes therapy required 
because of an absent or malfunctioning body part that normally permits food to reach the digestive 
tract.  In these instances, Medicare Part B considers the service reasonable and necessary and 
covers claims for the enteral nutrients,6 along with the supplies, and equipment necessary for 
 
4
 Centers for Medicare & Medicaid Services (CMS), Medicare Claims Processing Manual, Pub. No. 100-04, ch. 7,  20.  All CMS manuals 
referenced in this report can be accessed at http://www.cms.gov/Manuals/IOM/list.asp?intNumPerPage=all&submit=Go.    
5
 CMS, Medicare Claims Processing Manual, ch. 20,  100.2.2.2.   
6
 Section 1842(s) of the Social Security Act authorized a fee schedule for many services, such as ENT associated nutrients, equipment, and 
supplies, that durable medical equipment (DME) Medicare Administrative Contractors (MAC) use to reimburse ENT claims. 
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administration (i.e., infusion pumps, intravenous (IV) poles, feeding supply kits, and tubing).  
Although not covered as durable medical equipment (DME), ENT equipment meets the definition 
of DME7 and reimbursement rules relating to DME continue to apply to such items.8      
CMSs payment contractors must ensure that ENT claims qualify as medically reasonable and 
necessary.  To partially ensure this, Medicare-enrolled suppliers had to submit, with the initial 
claim, a Certificate of Medical Necessity (CMN) containing a clinical attestation by the treating 
physician as to the medical necessity of the enteral nutrients, supplies, and equipment.9  From  
October 1 through December 31, 2006, CMNs were replaced by a DME Information Form (DIF),  
which does not contain the treating physicians clinical documentation as to medical necessity.10   
During the transition period, MACs could accept either a CMN or a DIF.  In addition to the DIF,  
suppliers and other providers must ensure sufficient documentation in a patients medical records to 
provide medical justification for the use of equipment.11     
Mandate for Office of Inspector General To Monitor Part B Payments 
With the repeal of the Balanced Budget Act of 1997s (BBA)12 consolidated billing provisions for 
non-Part A  stays,13 section 313(d) of the Medicare, Medicaid, and SCHIP Benefits Improvement 
and Protection Act of 2000 (BIPA)14 directed the Office of Inspector General (OIG) to conduct 
monitoring of Medicare Part B payments during non-Part A stays to ensure that there are no 
excessive services provided.15   As part of this monitoring, OIG recently completed evaluations of 
DME use16 and enteral nutrient pricing.17   Two ongoing evaluations include a medical record 
review of mental health services claims and an overview of Part B services during non-Part A  
nursing home stays. 
 
7
 CMS defines DME as equipment that can withstand repeated use, serves primarily a medical purpose, is not generally useful to a person in the 

absence of an illness, and is appropriate for use in a residents home.  Medicare Part B does not cover DME in a nursing home that primarily 

provides a skilled level of care or rehabilitation (nearly all certified nursing homes meet this level of care).  However, Part B, under the prosthetic 

device benefit, covers ENT equipment and associated supplies that would not otherwise be covered as DME.  For example, in non-Part A nursing 

home stays, Medicare Part B paid for IV poles used for enteral feeding, but would not have paid for their use in a nursing home for other 
 
purposes. 
 
8
 CMS, Medicare Claims Processing Manual, Pub. No. 100-04, ch. 20,  160.1. 
       
9
 CMS, Medicare Claims Processing Manual, Pub. No. 100-04, ch. 20,  100.2.2. 
  
10
 CMS, CMS Manual System, Transmittal 167, Change Request 4296 (Oct. 27, 2006).  

11
 CMS, Medicare Program Integrity Manual, Pub. No. 100-08, ch. 5,  5.7. 
 
12

 P.L. 105-33.  
13
 Section 4432 of the BBA established a prospective payment system for  Part A stays and required nursing homes to arrange for and consolidate 
into a single Medicare bill the Part  B services that a resident needs during his or her nursing home stay. 
14
 P.L. 106-554.  
15
 Section 313 of the BIPA maintained consolidated billing for Part A stays and therapy  services (regardless of Part A coverage), but repealed 
consolidated billing requirements for non-Part A stays.  Therefore, claims for beneficiaries during non-Part A stays continue to be individually 
 
submitted by suppliers and providers, except for therapy services. 

16
 OIG,  Part B Services During Non-Part A Nursing Home Stays:   Durable Medical Equipment (OEI-06-07-00100), July 2009. 
   
17
 OIG,  Medicare Part B Services During Non-Part A Nursing Home Stays:  Enteral Nutrient Pricing (OEI-06-07-00590), January  2010. 
   
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Related Work  
OIG has issued a number of reports on ENT services provided to Medicare beneficiaries.  These 
prior evaluations reported:18 
  excessive Medicare payments for enteral nutrients when compared to the actual cost of their 
purchase, and the need for payment restructuring, particularly as related to ENT supplies and 
equipment; 
  that enteral nutrients should be redefined as food for Medicare payment purposes and thus, 
should not be billed to Part B but included in a nursing homes daily rate; and 
  that 20 percent of beneficiaries in 1995 either did not meet coverage guidelines or had 
insufficient or conflicting documentation in their medical records that raised questions about 
the appropriateness of the claim.    
Recommendations from these studies to address the identified concerns about excessive Medicare 
payments included consolidated billing, competitive bidding for enteral nutrition products, and 
application of CMSs authority to use inherent reasonableness in pricing ENT.  CMS agreed that 
Medicare reimbursement for ENT was excessive and that there was a need for payment 
restructuring.  However, CMS noted that any payment restructuring and related definitional 
changes would require changes in legislation.  CMS also agreed with the recommendation relating 
to consolidated billing.  Past OIG reviews supported CMSs seeking changes in legislation to 
exclude enteral nutrients, supplies, and equipment from Part B reimbursement for residents in 
nursing homes primarily engaged in providing skilled care or rehabilitation.  Such legislation 
would seek to treat the provision of ENT as room and board costs and thereby include it in the 
facilitys daily room rate.  CMS further agreed with the need to apply its authority to establish a 
process for competitive bidding for enteral nutrition products and inherent reasonableness.  
Payment Errors Identified and Reviewed by CMS  
In 2002, CMS established the Comprehensive Error Rate Testing (CERT) program to review 
approximately 100,000 randomly selected claims for payment accuracy.  The CERT reviews result 
in annually published reports by CMS, and identify the degree to which sampled claims complied 
with Medicare coverage, coding, and billing regulations.   
According to the 2006 CERT report, enteral nutrition claims had an error rate of 1.7 percent and a 
projected improper payment amount of $9 million.  Most of these errors (59.4 percent) were 
attributed to lack of documentation and 40 percent were coding errors.  Less than 1 percent of the 
error rate was attributed to medically unnecessary services.19  However, these CERT results are not 
 
18
 OIG, Coverage of Enteral Nutritional Therapy:  Medicare and Other Payers (OEI-03-94-00020), May 1995; Enteral Nutrient Payments in 
Nursing Homes (OEI-06-92-00861), March 1996; Payments for Enteral Nutrition:  Medicare and Other Payers (OEI-03-94-00021), May 1996; 
Medicare Payments for Enteral Nutrition Therapy Equipment and Supplies in Nursing Homes (OEI-06-92-00866), May 1997; Enteral Nutrition 
Therapy:  Medical Necessity (OEI-03-94-00022), June 1997; Medicare Payments for Enteral Nutrition (OEI-03-02-00700), March 2004; and 
Medicare Part B Services During Non-Part A Nursing Home Stays: Enteral Nutrient Pricing (OEI-06-07-00590), January 2010. 
19
 CMS, Long Report  Improper Medicare Fee-For-Service Payments Report, November 2006. 
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comparable with our studys results because of the methodological differences between the two 
reviews.  For example, the CERT focuses on a random sample of all claims submitted to 
Medicares fee-for-service program, whereas this review focused solely on a random sample of 
Part B ENT claims submitted during non-Part A nursing home stays.   
METHODOLOGY 
Scope 
For this study, we identified all Part B ENT claims associated with beneficiaries during non-Part A 
nursing home stays in 2006.  We conducted a medical necessity, documentation, and coding review 
of a stratified random sample of ENT claims, which included nutrients; supplies (e.g., tubing); and 
equipment (e.g., pumps).   
Identification of ENT Claims During Non-Part A Nursing Home Stays 
We utilized several databases obtained from CMS to identify Part B payments allowed for ENT 
claims during non-Part A nursing home stays.  These databases included the MDS, the Online 
Survey Certification and Reporting system (OSCAR), the Enrollment Database (EDB), and the 
National Claims History (NCH).     
Minimum Data Set.  The MDS is a core set of screening, clinical, and functional status elements, 
including common definitions and coding categories, which forms the foundation of the 
comprehensive assessment for all residents of long-term care facilities certified to participate in 
Medicare or Medicaid.20  It includes information about each residents health, physical functioning, 
mental status, and general well-being, as well as nursing home admission and discharge dates.  
Each nursing home reports these individual assessments electronically to the State upon admission 
and updates them at least quarterly.21  The States subsequently transmit the MDS data to CMS.  We 
used the MDS (version 2.0) to identify all assessed nursing home residents in 2006 and their  
Social Security numbers (SSN), related nursing homes, and nursing home stay dates.  To determine 
resident stay dates between January 1 and December 31, 2006, we extracted all nursing home 
admission and discharge dates for each resident.  We used assessment dates as proxies for missing 
admission or discharge dates according to the following assumptions: 
  Missing Admission Date.  If the resident was in the nursing home on January 1, 2006 
(determined from subsequent assessments that the nursing homes conducted), we used the date 
of the first assessment conducted in 2005 as the admission date.   
  Missing Discharge Date.  We defined the date of the last assessment (received through  
March 2007) as the discharge date.   
 
20
 CMS, Resident Assessment Instrument Version 2.0 Manual, December 2002, ch. 1, p. 4. 
21
 More assessments are required for stays paid under the Part A SNF benefit. 
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Online Survey Certification and Reporting system.  The OSCAR database contains nursing home 
facility demographic information as well as survey results from nursing home certification and 
complaint surveys.  To obtain information about the nursing home (e.g., facility name, address, 
number of beds, and SNF, NF or dual SNF/NF certification), we linked the MDS facility 
identification numbers with the facility numbers maintained in OSCAR.   
Enrollment Database.  The EDB includes beneficiary-level data (e.g., name, SSN, and Medicare 
Health Insurance Claim Number (HICN)).  Using this database, we matched SSNs contained in the 
MDS file to SSNs in the EDB to identify Medicare beneficiaries and their associated HICNs.  We 
excluded beneficiaries having no matching SSN from further analysis.   
National Claims History.  The NCH is a data reporting system that includes both Part A and Part B 
claims.  We used the NCH to identify ENT claims allowed by Part B during non-Part A nursing 
home stays.  To identify ENT claims associated with Medicare beneficiaries with nursing home 
stays (identified earlier), we first matched their HICNs to claims with ENT services HCPCS codes.  
This match identified ENT claims allowed for Medicare beneficiaries during all nursing home 
stays.  To identify claims only during non-Part A stays, we then removed all claims for Part A paid 
stays 22 and inpatient hospital stays by matching the stay dates from the MDS to the SNF and 
inpatient hospital claims in the NCH.  The resulting dataset comprised all ENT claims for which 
billing was allowed under Part B during non-Part A nursing home stays in 2006.  See Appendix A 
for a list of ENT HCPCS codes used in this report. 
Sample Design 
From the dataset of ENT claims (enteral nutrients, supplies, and equipment) for beneficiaries in 
non-Part A nursing home stays during 2006, we selected two samples.  First, we randomly selected 
30 ENT claims for a sample used to pretest the medical review process (i.e., protocols).  Following 
the pretest, we identified a larger sample for the evaluations medical review.  For the medical 
review sample, we divided the population into two strata based on the allowed amount for each 
service.  The first stratum contained ENT claims with allowed charges of $340 or less, and the 
second stratum contained ENT claims with allowed charges of more than $340.  We randomly 
selected 175 claims from each stratum.  The resulting sample of 350 claims represented  
342 providers, 206 suppliers, 347 beneficiaries, and 337 nursing homes.  For these 350 claims, 
Medicare allowed $97,072.   
Prior to conducting the medical reviews, we identified three claims for which reviews could not 
be completed.  One claim was removed because of an ongoing investigation.  The other  
two claims were removed because the facility and provider records showed no record of ENT 
services and no Medicare billings.  The final sample of 347 claims was comprised of  
135 nutrient services (39 percent), 148 supply services (43 percent), and 64 equipment services 
(18 percent).  See Appendix A for the final distribution of the sample by strata.  
 
22
 OIG routinely conducts audits related to the issue of inappropriate Part B payments occurring during Part A stays.  As such, we excluded all 
Part A stays from our review. 
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Medical Review 
To conduct a medical review of the sample of Part B ENT claims, we obtained supplier contact 
information from DME MACs.  We also obtained medical records and documentation extending 
from 6 months prior to the date of the sampled claim(s) to 1 month following the date from the 
nursing homes, suppliers, and providers associated with the claims as well as any DIF or CMN 
relating to ENT services between 2005 and 2007.  When a provider did not respond to our initial 
request for documentation, we sent up to two followup request letters and conducted followup 
telephone calls for more information.  See Appendix B for a list of medical documents requested 
from nursing homes, suppliers, and providers. 
Identifying inappropriately allowed, inadequately documented, and medically unnecessary ENT 
claims.  We contracted with gastroenterologists and professional coders to review medical 
records for beneficiaries associated with the sampled claims.  The gastroenterologists determined 
adequacy of documentation (e.g., whether services were documented or had sufficient 
documentation), medical necessity of services, whether the services were rendered, the 
appropriateness of the methods of administration, the appropriateness of special formulas, and 
the adequacy of documented caloric intake.  The coders determined the accuracy of billed codes, 
including whether the HCPCS code on the claim for the service was upcoded, or downcoded.23   
We calculated Medicare-allowed claim amounts for inappropriate, medically unnecessary, and 
inadequately documented services.  Some of the sampled claims were inappropriate for more 
than one of these reasons.  However, in calculating the total Medicare-allowed claims paid in 
error, we adjusted for overlapping errors by counting claims with multiple errors only once.  
Standards 
This study was conducted in accordance with the Quality Standards for Inspections approved by 
the Council of Inspectors General on Integrity and Efficiency. 
RESULTS  
Twenty-one Percent of ENT Claims Allowed by Medicare Part B During Non-Part A 
Nursing Home Stays in 2006 Were Inappropriate or Inadequately Documented 
Based on the medical review, we estimate that the Medicare program allowed claims totaling  
$39 million for ENT services during non-Part A nursing homes stays in 2006 that were 
inappropriate or inadequately documented services.  (See Table 1.)   
 
23
 Upcoding is a practice in which a provider bills for a service using a higher reimbursement procedure code than warranted by the procedure 
actually performed, resulting in a higher payment by Medicare.  Downcoding is a practice in which the billing procedure code is changed to a 
lower reimbursement procedure code than was actually performed, resulting in a lower payment by Medicare. 
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Table 1.  Medicare Part B-Allowed Claims for Inappropriate and Inadequately Documented ENT 
Services During Non-Part A Nursing Home Stays in 2006 
Sample Claims  Projected 
Type of Error 
Inappropriately  Percentage of  Inappropriately 
Number of Claims 
Allowed Amount  Claims  Allowed Amount 
Inappropriate ENT Services  13  $2,502  4.9  -$1,542,228 
Inadequately Documented ENT 
57  $14,179  16.3  $40,843,794 
Services 
     Total Errors  69*    21.2  $39,067,966* 
*One claim was both inappropriate and inadequately documented, resulting in the projection total for 69 instead of 70 services.  As a result, the 
overlapping amount of $233,599 is not included in the results total. 
Source:  OIG medical review of Part B ENT services provided to beneficiaries during non-Part A nursing home stays in 2006. 
 
 
Five percent of ENT services were inappropriate.  Thirteen of the sampled claims represented 
services that the medical reviewers determined inappropriate.  Of these, eight claims reflected 
inappropriate levels of care for the resident and warranted higher payments.  These included the 
need for an upgraded method of administration (e.g., using the pump method instead of the syringe 
or gravity methods) and a claim that was downcoded inappropriately, resulting in a lower payment 
than should have been billed.  Conversely, 5 of the 13 sampled claims were nonrendered or 
upcoded inappropriately, thus warranting lower or no payments.  See Appendix C for related 
confidence intervals. 
When considering the cost difference between what Medicare allowed for these claims  
($10.8 million) and what we estimate Medicare should have allowed had the appropriate service 
been provided and billed, Medicare underpaid $1.5 million.24   
Sixteen percent of ENT claims were inadequately documented.  We estimate that Medicare allowed 
$40.8 million for inadequately documented ENT claims.  For a claim to be considered inadequately 
documented, the medical records lacked either a CMN or DIF, or sufficient documentation to 
determine: 
  whether ENT was medically necessary, when a CMN or DIF was not available; 
  whether the billed service was rendered; 
  accuracy of coding; or 
  whether a more expensive delivery system or special nutrient was medically necessary.   
Services for pump and pump supply kits represented 70 percent of the inadequately documented 
sampled claims (and an estimated 11 percent of all ENT claims).  We estimate that Medicare 
allowed $29.3 million for inadequately documented pump and pump supply kit claims.  For 40 of 
 
24
 Because the 95-percent confidence interval for the difference includes $0.00, we cannot determine whether Medicare overpaid or underpaid for 
these inappropriate ENT services, although our point estimate shows a $1.5 million underpayment. 
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the 160 sampled pump and pump supply kit claims (25 percent), reviewers could not verify that the 
pump method of administration was utilized.  Most medical records provided by the nursing homes 
contained the number of nutrient milliliters delivered during specified time intervals but failed to 
indicate that a pump was used to administer the nutrients.   
Although Satisfying Medicare Contractor Payment and Coverage Guidelines, 13 Percent of 
All ENT Claims Were Questionable Because the Pump Delivery Method Was Utilized 
Where a Less Expensive Delivery Method Was Available 
If a rate of administration less than 100 milliliters of enteral formula per hour is written on the 
CMN or DIF, Medicare contractors consider the pump medically necessary.25  Yet, both the 
pump delivery method and the gravity delivery method provide for a slow delivery rate of enteral 
nutrients.  Each of the 52 questionable pump and pump supply kit claims (estimated 13 percent 
of all claims) met Medicare contractor payment and coverage guidelines allowing payment based 
on a slow delivery rate of less than 100 milliliter per hour.  However, the medical reviewers 
found no evidence in the medical records of a medical condition (e.g., diabetes, risk of 
aspiration, or fluctuating glucose levels) warranting the use of the pump delivery system or a 
reason why the gravity method would not suffice for slow administration rates of less than  
100 milliliters of enteral formula per hour.26  We estimate that use of the pump delivery method 
represented $42.7 million in allowed payments.  See Appendix C for related confidence intervals.  
CONCLUSION  
This evaluation is consistent with prior OIG reports that have highlighted payment concerns  
related to ENT claims paid by Medicare Part B during nursing home stays.  In response to 
recommendations included in those reports, CMS commented that it planned to pursue a number of 
actions, such as evaluating the reasonableness of payment for enteral pumps and pursuing research 
of broader payment restructuring through capitation, competitive bidding, and bundling of ENT 
services.  While CMS has implemented consolidated billing for Part A stays and pursued 
competitive bidding, unconsolidated Part B claims during non-Part A stays continue to be 
vulnerable to inappropriate payments, primarily for lack of documentation.  Further, the current 
Medicare contractor payment and coverage guidelines for the use of the pump delivery method do 
not require documentation for a condition that necessitates only a pump and not the gravity 
method.  Consequently, nursing homes can continue to use the more expensive pump delivery 
method when the less expensive gravity delivery method is available.    
This report is being issued directly in final form because it contains no recommendations.  If you 
have comments or questions about this report, please provide them within 60 days.  Please refer to 
report number OEI-06-07-00090 in all correspondence. 
 
25
 Providers may utilize pump delivery when enteral patients experience complications associated with syringe or gravity method of 
administration.  Conditions often requiring the pump delivery method include unsatisfactory gravity feeding due to aspiration, diabetes, diarrhea, 
dumping syndrome, or fluctuating glucose levels.   
26
 Seventeen of these services were also inadequately documented. 
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APPENDIX A 
 
Table A-1:  Healthcare Common Procedure Coding System Enteral Nutrition Therapy Codes  
Sample Distribution 
First Stratum  Second Stratum 
Sample Total 
Enteral Nutrition Therapy (ENT)   ( $340)  (> $340) 
Healthcare Common Procedure 
Percentage  Percentage  Percentage  Percentage  Percentage  Percentage 
Coding System (HCPCS) Codes 
of Stratum  Allowed  of Stratum  Allowed  of Sample  Allowed  
(n)    (n)    (n) 
Nutrients 
B4150Nutritionally complete with  19.5%  29.0%  11.6%  10.6%  15.6%  15.0% 
intact nutrients  (34)  ($6,542)  (20)  ($7,694)  (54)  ($14,236) 
B4152Nutritionally complete,  6.9%  11.3%  1.2%  1.2%  4.0%  3.6% 
calorically dense, with intact  (12)  ($2,558)  (2)  ($878)  (14)  ($3,436) 
nutrients 
B41Nutritionally complete,  0.0%  0.0%  1.7%  3.3%  0.9%  2.6% 
hydrolyzed proteins (amino acids  (0)  ($0)  (3)  ($2,428)  (3)  ($2,428) 
and peptide chain) 
B4154Nutritionally complete, for  6.9%  8.3%  26.0%  34.1%  16.4%  28.0% 
special metabolic needs  (12)  ($1,880)  (45)  ($24,800)  (57)  ($26,680) 
B4155Nutritionally  4.0%  1.1%  0.0%  0.0%  2.0%  0.3% 
incomplete/modular nutrients,  (7)  ($244)  (0)  ($0)  (7)  ($244) 
includes specific nutrients 
37.4%  49.7%  40.5%  49.3%  38.9%  49.4% 
          Total Enteral Nutrients 
(65)  ($11,224)  (70)  ($35,800)  (135)  ($47,024) 
Supplies 
B4034Syringe feeding supply kit,  5.2 %  5.9%  0.0%  0.0%  2.6%  1.4% 
per day  (9)  ($1,325)  (0)  ($0)  (9)  ($1,325) 
B4035Infusion pump feeding  16.1%  20.5%  59.5%  50.7%  37.8%  43.6% 
supply kit, per day  (28)  ($4,627)  (103)  ($36,838)  (131)  ($41,465) 
B4036Gravity feeding supply kit,  2.3%  4.3%  0.0%  0.0%  1.2%  1.0% 
per day   (4)  ($976)  (0)  ($0)  (4)  ($976) 
B4086Gastrostomy/jejunostomy  2.3%  0.6%  0.0%  0.0%  1.2%  0.2% 
tube  (4)  ($142)  (0)  ($0)  (4)  ($142) 
25.9%  31.3%  59.5%  50.7%  42.7%  46.1% 
          Total Enteral Supplies 
(45)  ($7,070)  (103)  ($36,838)  (148)  ($43,908) 
Equipment 
B9002Infusion pump with alarm  16.7%  15.0%  0.0%  0.0%  8.4%  3.6% 
(29)  ($3,385)  (0)  ($0)  (29)  ($3,385) 
E0776Intravenous pole (must  20.1%  3.9%  0.0%  0.0%  10.1%  0.9% 
have a payment modifier attached  (35)  ($883)  (0)  ($0)  (35)  ($883) 
indicating use for enteral nutrients) 
36.8%  18.9%  0.0%  0.0%  18.4%  4.5% 
          Total Enteral Equipment 
(64)  ($4,268)  (0)  ($0)  (64)  ($4,268) 
50.1%  23.7%  49.9%  76.3%  100%  100% 
 ENT SAMPLE TOTAL 
(174)  ($22,562)  (173)  ($72,638)  (347)  ($95,200) 
Note:  HCPCS codes B4035 (infusion pump kit) and B9002 (infusion pump) together represent 46.2 percent of sample and 47.2 percent of the allowed 
amount.  HCPCS code B4154 (special nutrient) represented 16.4 percent of sample and 28.0 percent of the allowed amount. 
Source:  Office of Inspector Generals sample of 347 Part B ENT claims during non-Part A nursing home stays during 2006. 
 
OEI-06-07-00090  Medicare Part B Services During Non-Part A Nursing Home Stays:  Enteral Nutrition Therapy     
                   
 
 
 
Page 11  Marilyn Tavenner 
 
 
 
APPENDIX B  
 
Table B-1:  Medical Record Documents Requested From Nursing Homes, Suppliers, and 
Providers 
ALL Certificate of Medical Necessity forms [CMS-853] during 2005 through 2007 pertaining to enteral nutrition therapy (ENT) 
ALL Durable Medical Equipment Information Forms [CMS-10126] during 2006 through 2007 pertaining to ENT 
The following documents for period of 6 months prior to identified service to 1 month following service: 
Physician orders to include telephone and verbal orders 
Physician progress notes 
Gastrointestinal endoscopy procedure notes (including gastrostomy, jejunostomy) 
Gastroenterology office or ambulatory surgery notes 
History & Physical notes 
Swallowing studies 
Daily medication administration record 
Intake & output records 
Nurse progress notes 
Daily dietetic/ENT records 
Flow sheets documenting enteral nutrition administration 
Other progress notes 
Discharge summaries for any inpatient stays during 2006 
Any other information concerning medical necessity/administration of enteral nutrition 
Source:  Office of Inspector Generals evaluation of 347 Part B ENT claims for non-Part A nursing home stays during 2006. 
 
 
OEI-06-07-00090  Medicare Part B Services During Non-Part A Nursing Home Stays:  Enteral Nutrition Therapy     
                   
 
 
 
Page 12  Marilyn Tavenner 
 
 
APPENDIX C  
 
Confidence Intervals for Selected Estimates 
 
Table C-1:  Inappropriate and Inadequately Documented Enteral Nutrition Therapy Claims 
During Non-Part A Nursing Home Stays in 2006* 
95-Percent 
Statistic  N  Estimate 
Confidence Interval 
Total allowed amount for inappropriate services  13  $10,820,269  $4,290,981$17,349,557 
Of all claims, percentage that were inappropriate   13  4.9%  2.88.3% 
     Quality-of-care issues  7  2.9%  1.46.0% 
     Nonrendered service  1  0.2%  01.1% 
     Miscoded claims  5  1.8%  0.74.4% 
            Upcoded  4  1.4%  0.53.9% 
            Downcoded  1  0.4%  0.12.9% 
Amount Medicare should have allowed for 
13  $12,362,498  $4,083,228$20,641,768 
inappropriate claims 
Improperly allowed amount for inappropriate claims 
(total allowed amount minus amount that should  13  -$1,542,228  -$5,303,772$2,219,315 
have been allowed) 
Improperly allowed amount for inadequately 
57  $40,843,794  $29,304,063$52,383,526 
documented claims 
Of all claims, percentage that were inadequately 
57  16.3%  12.521.0% 
documented 
Improperly allowed amount for inadequately 
40  $29,276,858  $19,493,371$39,060,345 
documented pump claims 
Of all claims, percentage that were  
40  11.3%  8.115.4% 
Inadequately documented pump claims 
Improperly allowed amount for inadequately 
documented (other than inadequately documented  17  $11,566,936  $4,841,686$18,292,187 
pump claims) 
Of all claims, percentage that were inadequately 
documented (other than inadequately documented  17  5.0%  3.08.3% 
pump claims) 
Overlapping amount (improperly allowed amount for 
claims that were both inappropriate and  1  $233,599  ** 
inadequately documented) 
Overlapping percentage (of all claims, percent that 
were both inappropriate and inadequately  1  0.2%  01.1% 
documented) 
Improperly allowed amount for all  inappropriate or 
69  $39,067,966  $26,899,737$51,236,196 
inadequately documented claims 
Of all claims, percentage that were inappropriate or 
69  21.0%  16.626.1% 
inadequately documented 
*Sample size=347; N=number in sample.   
**Because there was only one claim in the sample, we could not calculate a 95-percent confidence interval for the (overlapping) inappropriately 
allowed amount. 
Source:  Office of Inspector Generals sample analysis and projections of 347 Part B enteral nutrition therapy (ENT) claims for non-Part A 
nursing home stays during 2006. 
 
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Page 13  Marilyn Tavenner 
 
 
 
Table C-2:  Medically Unnecessary Pump Use* 
95-Percent 
Statistic  N  Estimate 
Confidence Interval 
Amount for unjustified pump use  52  $42,702,684  $31,092,192$54,313,177 
Percentage of claims with unjustified 
52  13.0%  9.717.1% 
pump use 
*Sample size=347; N=number in sample  
Source:  Office of Inspector Generals sample analysis and projections of 347 Part B ENT claims for non-Part A nursing home stays during 
2006. 
 
 
 
OEI-06-07-00090  Medicare Part B Services During Non-Part A Nursing Home Stays:  Enteral Nutrition Therapy