January,
2007
Today's
CPE: Medicare Reimbursement of Home Nutrition Support
By Mike Nelson, RD, CNSD
Today’s Dietitian
Vol. 9 No. 1 P. 12
Learning Codes: 4080, 5000, 5220,
5440; CDR Level 2
In 1965, when Medicare was established as Title
XVIII of the Social Security Act, nutrition support was virtually
unknown and rules for the care of older adults, those with permanent
disabilities, and patients with end-stage renal disease were
simple. Today, both enteral and parenteral nutrition are included
in the prosthetic device benefit provision of Part B of Medicare,
which covers items that replace an organ or perform the function
of a permanently inoperative or malfunctioning organ. The benefit
covers supplies, equipment, and nutrients. (Medicare defines
permanent as more than 90 days.)
Because the number of older adults covered by
the benefit is likely to grow over the coming decades and because
home care is becoming an increasingly attractive and necessary
option for their care, home nutrition support will become even
more important than at present. Dietitians can play a vital
role in ensuring good care decisions—provided they understand
the regulations and procedures, which are always evolving. This
article will introduce dietitians to Medicare terminology, guidelines,
and issues surrounding the utilization of home parenteral and
enteral nutrition (PEN).
Medicare Part B is an optional program, and
reimbursement for PEN support involves procedures and commitments
from both beneficiaries and suppliers. The beneficiary needs
to sign up for Part B to obtain coverage; the supplier will
need to understand Medicare’s reimbursement system to
follow its procedures. Criteria for reimbursement are fairly
strict, and some home patients who could benefit from PEN may
not be covered. For example, a patient may need parenteral nutrition
for only 60 days, therefore not meeting the Medicare condition
of permanence.
Dietitians have opportunities to help suppliers
understand and improve compliance with the rules for reimbursement
PEN therapies. Of first importance is communication. The Medicare
system uses terminology and acronyms that dietitians may not
recognize. In the following paragraphs, we’ll work through
some of this bureaucratic alphabet soup—especially important
since a new form is required beginning this month.
• Durable Medical Equipment Medicare Administrative
Contractors (DME MAC) — Patients with Medicare are assigned
to one of four DME MAC, based on the beneficiary’s address.
For example, a beneficiary who lives in Iowa is in jurisdiction
D and Noridian Administrative Services handles their claims.
The Centers for Medicare & Medicaid Services (CMS) contracts
with the DME MAC for processing Medicare claims for durable
medical equipment, orthotics, and prosthetics (which includes
PEN supplies, equipment, and nutrients). DME MAC, their Web
sites, and the states they cover are listed in Table
1.
• Statistical Analysis Durable Medical
Equipment Regional Contractors (SADMERC) — Medicare also
contracts for a SADMERC to assist the CMS as a resource for
suppliers in determining appropriate Healthcare Common Procedure
Coding System (HCPCS) Level II codes when submitting claims
to Medicare. The HCPCS code identifies the Durable Medical Equipment,
Prosthetics, Orthotics, and Supplies (DMEPOS) being billed.
The current SADMERC contractor is Palmetto GBA. (See their Web
site for the complete DMEPOS Fee Schedule: www.palmettogba.com.)
Tables 2 and 3 list some
common PEN items and their HCPCS and DMEPOS Fee Schedule.
The HCPCS is a standardized coding system. PEN
codes, maintained by the CMS, are alpha-numeric, consisting
of a single alphabetical letter followed by four numeric digits.
For example, B4150 is the HCPCS code for enteral formula, nutritionally
complete with intact nutrients, including protein, fats, carbohydrates,
vitamins and minerals, and possibly fiber. B4150 products are
administered through an enteral feeding tube with 100 kilocalories
equalling 1 unit. A common enteral product classified as B4150
is Nutren 1.0. See Tables 3
and 4 for a list of common HCPCS codes for enteral and parenteral
products.
In addition, the SADMERC assists the CMS with
the DMEPOS Fee Schedules and analyzes DMEPOS fees to identify
unreasonable or excessive reimbursement amounts. Payment on
a fee schedule basis is required for PEN—fees are updated
annually. For example, the fee increased by approximately 2.6%
in 2006.
The fee schedules list includes allowables or
the amount of money Medicare would pay for a product if Medicare
paid 100%. However, Medicare was designed to pay for 80% of
the allowables. If a beneficiary has Medicare Supplement Insurance
coverage, the insurance supplement will pay for the 20% not
covered by Medicare. For example, a supplier bills for 180 cans
of Nutren 1.0 (250 kilocalories per can) for one month of feeding.
One hundred eighty cans of Nutren have 45,000 kilocalories,
or 450 units. The Medicare allowable for 450 units is $301.50
($0.67 per unit); thus, Medicare will pay 80% of $301.50, or
$241.20.
The SADMERC also provides services to manufacturers
to help them categorize their products. For example, if a manufacturer
creates a new enteral product, the manufacturer will contact
the SADMERC to categorize and assign an HCPCS number and fee.
• DME Information Form (DIF) — To
receive Medicare reimbursement for PEN, a supplier will need
to complete a DIF and send to its DME MAC. The DIF is a form
required to help document the medical necessity of PEN therapy.
This form replaced separate Certificate of Medical Necessary
(CMN) forms for PEN, which had been used for this purpose, on
January 1. Only DIF forms will be accepted by the DME MAC and
will be available from the DME MAC.
The most significant change from CMN to DIF
is that the supplier can now complete and sign the DIF, which
should speed up the claims process for suppliers. In the past,
a portion of the CMN needed to be completed and signed by the
physician, which could lead to many delays in obtaining reimbursement
for the supplier. Many times it was a struggle for the supplier
to get the completed CMN back from the physician in a timely
manner. Other times the information would be incorrect and would
need to be sent back for correction. Making it even more difficult,
Medicare regulations forbid the suppliers from assisting the
physician in completing the CMN.
The DIF form requires some basic information
such as the patient’s name, address, phone number, Medicare
number, date of birth, gender, height, and weight. The supplier’s
name, address, phone number, and Medicare supplier number, and
the physician’s name, address, phone number, and physician
identification. The DIF form also requires certain code numbers
are also required. The proper diagnosis code (International
Classification of Diseases, Ninth Revision [ICD-9]) needs to
be documented to justify PEN therapy. (Coverage issues for PEN
will be discussed later in this article.) See Tables
5 and 6 for some common ICD-9 codes for PEN.
In addition, the correct HCPCS codes for products
delivered to the patient need to be added to the DIF. Refer
to Tables 2 and 3 for some
common HCPCS codes for PEN. Also, the correct code number for
the place of service needs to be included on the DIF. The most
common number is “12,” which identifies the patient’s
home. (Using the code number “31,” identifying a
skilled nursing facility, will result in the claim being denied
since those facilities get reimbursement from other Medicare
sources other than Part B.)
The estimated length of service needs to be
recorded on the DIF. This number represents the number of months
the patient is anticipated to be on the therapy unless the patient
is expected to remain on PEN for life, in which case the number
“99” is used. Many enteral patients with significant
dysphagia have an estimated lifetime code. If the number of
months is less than three, the claim will be denied since it
does not meet the condition of permanence.
There are specific enteral and parenteral questions
on the DIF. To obtain reimbursement for enteral therapy, questions
1 through 6 must be answered; for parenteral therapy, questions
6 through 9 need to be completed.
• Enteral question 1 requires documentation
that the patient has a permanent inability to permit food to
reach or be absorbed from the small intestine. Medicare considers
the test of permanence to be three months or more or at least
the anticipation of three months or more of therapy.
• Enteral question 2 requires the supplier
to document that the patient is receiving the product via tube.
Nutrition products taken orally are not covered by Medicare.
• Enteral questions 3 and 4 require the
product’s HCPCS code and the number of calories per day
from that product. For example, Nutren 1.0 is HCPCS code B4150.
For six cans per day of Nutren 1.0, the patient would receive
1,500 kilocalories daily. See
Table 4 for common HCPCS enteral codes.
• Enteral question 5 asks for the method of administration
(eg, syringe, gravity, pump, or oral routes). Medicare will
not cover enteral nutrition in which the method of administration
is oral, and the method of administration must correspond to
the supply kit being used. For example, if a supplier circles
“pump” as the method of administration but gives
the HCPCS code for gravity feeds, the DME MAC will either defer
processing the claim to require a correction or reimburse at
the lowest rate, which would be that for syringe-fed supplies.
• Question 6 must be answered for both
enteral and parenteral therapy. The question asks how many days
per week the therapy is being administered or infused. If a
supplier answers something other than seven days per week, the
claim may be denied or delayed for Medicare to determine why
the patient is not receiving therapy every day.
• Parenteral question 7 wants the supplier
to document that the patient has a permanent (90 days or longer)
disease of the gastrointestinal (GI) tract that causes malabsorption
severe enough to prevent the patient from maintaining weight
and strength. If the patient does not have a long-term problem
with intestinal digestion or absorption, Medicare will not cover
parenteral nutrition. (Parenteral nutrition coverage is discussed
in more depth later in the article.)
• Parenteral question 8 requires the supplier
to document the parenteral prescription for amino acids, dextrose,
and lipids. Medicare reimburses parenteral nutrition as a two-in-one
solution, separating claims for the amino acids, dextrose, electrolytes,
vitamins, and trace elements solution from those for lipids.
The DME MAC will question and probably ask for additional justification
for amino acids outside the range of 0.8 to 1.5 grams per kilogram
per day or dextrose amounts less than 10%. The maximum amount
of lipids Medicare will normally cover is 50 grams per day.
• Parenteral question 9 asks the supplier
to document the access line for the parenteral nutrition administration.
The choices are central line (including peripherally inserted
central catheters), hemodialysis access, and peritoneal catheter.
The most common access line choice is the central line.
The supplier then needs to sign and date the
DIF, indicating that all the information on the form is accurate.
Medicare can audit charts for medical justification for PEN
therapy and can charge suppliers with fraud if the information
in the medical record doesn’t justify the therapy and
reimbursement.
Dietitians have an opportunity to widen their
job responsibilities and become valuable team members in the
reimbursement process by helping claim processors correctly
fill out the clinical portions of the DIF. This can help justify
the dietitian’s expense to the supplier by ensuring DIF
accuracy, which results in a quicker reimbursement cycle for
the supplier with a more efficient billing system.
As noted, Medicare Part B patients need to meet
certain criteria prior to qualifying for coverage of their enteral
feeding, equipment, and supplies: a permanent dysfunction that
inhibits food reaching the small intestines or a small bowel
disease that impairs digestion or absorption of an oral diet.
(For example, dysphagia from esophageal cancer will not permit
food to reach the intestines.) The enteral product needs to
be delivered via tube; oral products are not covered by Medicare.
(So if a patient is drinking Ensure—not receiving it via
tube—the product, equipment, and supplies are not covered).
In addition, tube feedings need to provide sufficient
nutrients to maintain weight and strength commensurate with
the patient’s overall health status. Adequate nutrition
must not be possible by dietary adjustments and/or oral supplements.
If the preceding requirements are met, Medicare
will cover medically necessary nutrients, administration supplies,
and equipment (eg, tubes, syringes, and dressings). However,
coverage is possible for patients with partial impairment who
can eat small amounts of food but need tube feedings to maintain
their weight and nutritional status—for example, a patient
with Crohn’s disease who is able to eat some food but
needs prolonged tube feeding to overcome his or her problem
with absorption.
Some common situations that are not covered
by Medicare are patients who need enteral nutrition due to anorexia,
nausea, or an end-stage disease but have a functioning GI tract
and no obstruction or malabsorption problems.
Enteral
Formula Coverage
Once the patient meets Medicare enteral criteria, his or her
formula will be covered. Formulas are classified (by composition)
in the Product Classification List (PCL) published by the SADMERC.
To bill Medicare, the supplier will need to use the PCL to correctly
code the claim. Although most Medicare patients are over the
age of 65, the list does classify pediatric formulas. Please
consult the Web page for the complete listing of enteral formulas:
www.palmettogba.com. (See Table
4 for common product classifications.)
Medicare considers the enteral formulas in the
B4150 or B4152 groups appropriate for the majority of patients
requiring enteral nutrition and needs no additional medical
justification; most tube feeding products utilized for home
enteral patients will be classified within these two categories.
However, Medicare requires additional medical justification
for the other common classifications: B4149, B4153, B4154, and
B4155.
For example, the use of a diabetic formula such
as Glucerna (B4154) will need additional justification. The
patient will need to try a B4150 formula first. If it results
in an inability to control the patient’s blood glucose
levels, the need for improved blood glucose control will justify
Glucerna.
If medical justification for B4149, B4153, B4154,
and B4255 formulas are not substantiated, the payment to the
supplier will be based on the allowance for the least costly
B4150 formula. This can cause a reimbursement problem since
most formulas that need additional justification cost more than
the B4150 allowable fee amounts. See Table
3 for the fee schedules for the various enteral formulas.
Method of Administration
Medicare will pay for “supply kits” to administer
enteral formulas. There are three supply kits: syringe fed,
gravity fed, and pump fed. Typical supplies include bags, tubing,
syringes, dressing, and tape. Items may differ from patient
to patient and day to day.
Typical patients will use a 60-milliliter syringe to feed themselves,
since this is the quickest and easiest method of administration.
However, if the patient is unable to tolerate the high rate
of feeding from a syringe, he or she can try gravity feeds.
(The gravity feeding rates can be slowed with a roller clamp
on the tubing of the bag.) In that case, a supplier would deliver
30 gravity bags, four 60-milliliter syringes for water flushes,
one tube adapter, and a roll of tape each month.
If the patient is unable to tolerate gravity
feeding, an enteral pump can be utilized. The use of an enteral
pump at home will require additional justification for reimbursement.
Examples of medical justification where gravity feeding is not
satisfactory include reflux and/or aspiration, severe diarrhea,
dumping syndrome, a need for a pump rate less than 100 milliliters
per hour, blood glucose fluctuations, circulatory overload,
or need for a jejunostomy tube.
The patient has the option of having the enteral
pump purchased by Medicare or rented by the month. It is unusual
for patients to choose the purchase option since it would be
the patient’s fiscal responsibility for maintenance and
servicing of the pump—usually a patient rents the pump.
Medicare caps the number of months for renting
pumps at 15. After 15 months, the supplier is still responsible
for ensuring that the patient has a pump for the duration of
medical necessity and maintaining and servicing the pump during
duration of the therapy.
Medicare reimburses separately for IV poles and enteral tubes.
If an IV pole is needed for gravity feeding or a pump, Medicare
will either purchase or rent the pole. Medicare reimburses for
one gastrostomy or jejunostomy tube every three months.
Parenteral
Nutrition Coverage
Medicare covers parenteral nutrition for patients with permanent,
severe pathology of the alimentary tract, which does not permit
absorption of sufficient nutrients to maintain weight and strength
commensurate with the patient’s general condition.
A parenteral nutrition permanent impairment
test is met if the patient is anticipated to be receiving parenteral
nutrition for 90 days or more. If the patient is on parenteral
nutrition for less than 90 days but was anticipated to be on
longer at the initiation of the therapy, Medicare should still
cover the claim.
The patient must have a condition involving
the small intestine (and/or its exocrine glands) that impairs
absorption of nutrients and/or a motility disorder that impairs
the ability of nutrients to be transported through the GI tract.
For example, short bowel syndrome impairs absorption of nutrients
and would qualify.
Medicare covers parenteral nutrition as a last
resort at maintaining a patient’s nutritional status.
It must not be possible to maintain a patient’s weight
and strength by modifying the nutrient composition of the diet—oral
or enteral—or utilizing pharmacologic means to treat the
etiology of the malabsorption problem (eg, pancreatic enzymes).
It is possible for parenteral nutrition to be
covered for a patient who obtains partial nutrition from either
the oral or enteral route. The specific criteria are spelled
out later in this article.
Medicare considers the caloric range of 20 to
35 kilocalories per kilogram per day as sufficient to achieve
or maintain weight. Caloric amounts other than 20 to 35 kilocalories
per kilogram per day will need to be justified and documented
in the medical record. For example, if an underweight patient
is unable to gain weight with 35 kilocalories per kilogram per
day, a parenteral nutrition solution can be increased to 40
kilocalories per kilogram per day.
Amino acid amounts outside the range of 0.8
to 1.5 grams per kilogram per day must be justified and documented
in the medical record. For example, the serum albumin of a patient
with pancreatitis continues to decline with 1.5 grams per kilogram
per day, requiring the parenteral nutrition’s amino acid
concentration to be increased to 2 grams per kilogram per day
to improve his or her serum albumin level.
Any dextrose concentration less than 10% will
need to be justified and documented in the medical record. Medicare
considers dextrose concentrations less than 10% only partial
parenteral nutrition and not enough nutrition to maintain weight
and strength.
Medicare covers 50 grams per day of lipids or
less with parenteral nutrition; 50 grams of lipids is 166 milliliters
of 30% lipids, 250 milliliters of 20% lipids, or 500 milliliters
of 10% lipids. The number of milliliters of lipids being used
per day is important because the DIF requires documentation
of the lipid percentage and the number of milliliters. If a
supplier is utilizing more than 50 grams per day, Medicare may
not reimburse a claim for more than 50 grams and the supplier
will need to account for this decrease in reimbursement, making
adjustments if necessary.
Specific Coverage
Along with general criteria a patient needs to meet to qualify
for Medicare coverage for parenteral nutrition, the patient
will need to meet specific conditions.
Medicare’s specific criteria for coverage
of parenteral nutrition is divided into seven sections: A through
G/H. Medicare requires a patient to meet these specific situations
to qualify for parenteral nutrition. All situations will require
documentation in the medical chart justifying the claim.
• Situation A is for a patient who has
had a small bowel resection and has less than 5 feet (152 centimeters)
of small bowel left beyond the ligament of Treitz. The surgery
needs to have occurred within the previous three months. Many
times surgeons will not document the amount of small bowel left
after a small bowel resection, making it difficult to justify
a patient’s therapy under this Medicare situation. If
possible, try to ask that this length be documented.
• Situation B is for a patient with short
bowel syndrome diagnosis who has lost more than 50% of his or
her oral or enteral intake. The patient needs to have an oral
intake of at least 2.5 to 3 liters per day and a urine output
of less than 1 liter per day. A dietitian can assist a supplier
by documenting the oral or enteral intake.
• Situation C is for a patient who requires
bowel rest because of symptomatic pancreatitis, severe regional
enteritis, or a proximal enterocutaneous fistula when a tube
feeding distal of the fistula is not possible. This is a straightforward
situation to document, requiring only the appropriate diagnosis
and meeting general parenteral coverage requirements.
• Situation D is for a patient who has
a complete mechanical small bowel obstruction where surgery
is not an option. This is another medical condition that only
requires a physician’s diagnosis determination.
• Situation E is for a patient who is
malnourished from malabsorption. The patient must have had a
10% or greater weight loss in three months or less, with a serum
albumin equal to or less than 3.4 grams per deciliter. The patient
will also need fecal fat test results that show fecal fat of
50% of the oral/enteral intake or higher on a diet of 50 grams
fat per day or more. Also, the patient will need a nutritional
assessment by a physician, dietitian, or other qualified professional
completed within one week prior to the initiation of the parenteral
nutrition. The dietitian can help the supplier by completing
a nutrition assessment of the patient.
• Situation F is for a patient who is
malnourished with chronic nausea and vomiting. The patient must
have had a 10% or greater weight loss in three months or less,
with a serum albumin of 3.4 grams per deciliter or less. The
patient also needs to be on maximum doses of prokinetic medication
(eg, Reglan) and have daily symptoms of nausea and vomiting.
The patient will also need an abnormal small bowel motility
study. Additional documentation is more extensive than previous
situations. Medicare requires a nutritional assessment from
a qualified professional within one week prior to initiation
of parenteral nutrition with:
- information on current weight and weight one
to three months prior;
- estimated daily calorie intake during the
prior month and a determination whether there were caloric losses
from vomiting or diarrhea and whether these estimated losses
are reflected in the calorie count; and
- a description of any dietary modifications
made or supplements tried during the prior month (eg, low-fat
diet with increased medium-chain triglyceride oil).
The dietitian is the most qualified professional
to assess all the previous nutritional elements, and he or she
will need to make sure to include all elements required by Medicare.
(Otherwise, the supplier may not receive reimbursement.) This
requires considerable effort—for example, the need to
document the patient’s caloric intake the previous month
prior to parenteral nutrition takes planning and a large amount
of documentation and work.
• Situation G/H. This situation encompasses
cases in which the patient needs parenteral nutrition but does
not fit into any of the previous situational criteria. The documentation
and criteria options are extensive. To qualify, the patient
must meet the following conditions:
- at least 10% weight loss in less than three
months;
- a serum albumin less than or equal to 3.4
grams per deciliter;
- altering the nutrient composition of an enteral
diet will not maintain the patient’s health status; and
- the patient’s health status cannot be
maintained by administering medications to treat the etiology
of the malabsorption.
If all four criteria are met, the patient must
then have one of the following moderate abnormalities:
• Seventy-two–hour fecal fat study
showing that fecal fat is greater than 25% of oral/enteral intake
on a diet with more than 50 grams of fat per day;
• a diagnosis of malabsorption with objective
confirmation by methods other than 72-hour fecal fat test (eg,
Sudan stain of stool, d-xylose);
• gastroparesis demonstrated by study
that shows the isotope, barium, or pellets failed to reach the
right colon in three to six hours or a manometric motility study
consistent with abnormal gastric emptying unresponsive to prokinetic
medication;
• small bowel motility disturbance unresponsive
to prokinetic medication demonstrated with a gastric to right
colon transit time between three and six hours;
• small bowel resection that left more
than 5 feet of small bowel beyond the ligament of Treitz;
• short bowel syndrome not as severe as
Situation B;
• mild to moderate exacerbation of regional
enteritis or enterocutaneous fistula; or
• partial mechanical small bowel obstruction,
where surgery is not an option.
If the criteria are met, the medical record
must document a failed tube trial.
Dietitians have an opportunity to expand their practice by assisting
suppliers of home PEN in improving their Medicare reimbursement.
They should begin now, with the introduction of new paperwork,
to advise and inform medical and administrative staff of their
role. The system is complicated, but it can be decyphered and
systems can be set up to make it work.
— Mike Nelson, RD, CNSD, is the clinical
nutrition manager at Mercy Medical Center Redding in California.
He coordinates nutrition support activities at this Level III
Neonatal Intensive Care Unit and Level II Trauma Center Hospital.
He has worked in home infusion and home health since 1988.
Resources
AdminaStar Federal, Inc., www.adminastar.com
Centers for Medicare & Medicaid Services,
www.cms.gov
Cigna, www.cignamedicare.com
National Heritage Insurance Company, www.medicarenhic.com/dme/index.shtml
Noridian Administrative Services, LLC, www.noridianmedicare.com
Ireton-Jones C, DeLegge M. Home parenteral nutrition
registry: A five-year retrospective evaluation of outcomes of
patients receiving home parenteral nutrition support. Nutrition.
2005:21(2):156-160.
Wojtylak F. Medicare enteral and parenteral
reimbursement: Requirements for successful coverage and payment.
Support Line. 2006;18(4):18-23.
Examination
1. Patients who live in New Mexico will have which Durable Medical
Equipment Medicare Administrative Contractors (DME MAC) process
their claims?
a. National Heritage Insurance Company
b. New York Life
c. AdminaStar Federal, Inc.
d. Cigna
e. Nordian Administrative Services
2. _________ assists the Centers for Medicare
& Medicaid Services with the Durable Medical Equipment,
Prosthetics, Orthotics, and Supplies Fee Schedules.
a. DME Information Form (DIF)
b. Statistical Analysis Durable Medical Equipment Regional Contractors
c. Healthcare Common Procedure Coding System (HCPCS)
d. Parenteral and enteral nutrition
e. DME MAC
3. What is the correct HCPCS for the enteral
formula Glytrol?
a. B4149
b. B4150
c. B4152
d. B4153
e. B4154
4. Which question is not on the DIF?
a. Print HCPCS code(s) of product?
b. Calories per day for each corresponding HCPCS code(s)?
c. How many calories per milliliter are in the HCPCS?
d. Circle the number for method of administration.
e. Days per week administered or infused?
5. Medicare will cover, without additional justification,
which amount of amino acids in parenteral nutrition solution?
a. 0.7 grams per kilogram per day
b. 1.6 grams per kilogram per day
c. 1.2 grams per kilogram per day
d. 2 grams per kilogram per day
e. 1.9 grams per kilogram per day
6. To meet the test of permanence, a patient
will need to be on parenteral nutrition for how many days?
a. 50 days
b. 60 days
c. 70 days
d. 80 days
e. 90 days
7. Medicare will cover the oral method of administration
for enteral nutrition.
a. True
b. False
8. What is not required for parenteral nutrition
coverage under Situation C?
a. Bowel rest for at least three months
b. Symptomatic pancreatitis
c. Serum albumin below 3.4 milligrams per deciliter
d. Severe exacerbation of regional enteritis
e. 20 to 35 kilocalories per kilogram per day
9. Medicare covers up to 50 grams of lipids
per day. Which of the following is equal to 50 grams of lipids?
a. 200 milliliters of 20% lipids.
b. 200 milliliters of 10% lipids.
c. 250 milliliters of 10% lipids.
d. 250 milliliters of 20% lipids.
e. 250 milliliters of 30% lipids.
10. The Medicare allowable for Jevity 1 Cal would be approximately:
a. $1.57 per 100 kilocalories.
b. $0.67 per 100 kilocalories.
c. $0.56 per 100 kilocalories.
d. $1.92 per 100 kilocalories.
e. $1.22 per 100 kilocalories.
