FARRELL Valve® Reimbursement Guidelines
The FARRELL Valve is a disposable, closed reservoir overflow device for adults / children receiving enteral feeding. It provides a pathway for backflow of stomach contents and containment of gastric feeding and medications until the stomach can accept and process the enteral feeding therapy.
Indicated for children and adults with reduced or impaired gastric motility and who cannot tolerate standard enteral feeding techniques. This can result in gastric reflux, putting the patient at risk for aspirating stomach contents, and abdominal distention which can result in pain, discomfort and inhibited lung expansion.
The system is utilized in conjunction with routine enteral feeding supplies for safe and effective feedings delivered by syringe, gravity, or via an electric enteral pump. It connects to any standard enteral feeding system, which then attaches to the primary gastric access device; naso-gastric or oro-gastric tube, percutaneous endoscopic gastrostomy (PEG) tube, gastrostomy tube (G-Tube, Low Profile Gastrostomy Tube (LPGD).
Coverage for Enteral Nutrition
Medicare and other payers usually include enteral nutrition as a covered benefit when patient status requires enteral therapy. Medicare covers enteral formula and supplies for Enteral Nutrition (EN) under the Medicare Part B prosthetic device benefit. Medicaid and private insurers usually provide EN under a Durable Medical Equipment (DME) benefit or an enteral nutrition benefit. Coverage is dependent upon the medical benefit plan and/or may be governed by state mandates and will differ significantly across insurance plans or Medicaid plans.
General coverage of enteral nutrition and supplies is based on medical necessity when the enteral therapy is the primary source of nutrition and when specified criteria are met. Each payer will provide the coverage criteria in their Enteral Nutrition Coverage Policy. It is best to refer to the applicable benefit plan information or coverage policy to determine the benefit availability and the terms, conditions and limitations of coverage.
HCPCS Codes for the FARRELL Valve® System
Enteral nutrition therapy which includes formula, nutritional solutions, medical supplies and enteral pumps are identified for billing by Healthcare Common Procedure Code System (HCPCS) codes. Each HCPCS code describes a particular type of nutritional formula or supply for delivery of the therapy.
The FARRELL Valve® System is a non-routine supply ordered for specific individuals receiving enteral nutrition who cannot tolerate their standard feedings due to severe distention, prolonged pain, and gastric reflux or vomiting.
Currently, there is no specific HCPCS code to describe the FARRELL Valve® System. Therefore payers have instructed providers and billers to utilize general miscellaneous HCPCS codes when billing for the FARRELL Valve® System.
- B9998: Miscellaneous enteral supply, not otherwise classified (most Medicaid programs and most private insurance)
- A9999: Miscellaneous DME supply or accessory, not otherwise specified (Medicaid in PA, NC)
- E1399: DME, miscellaneous (some private insurance)
- T5999: Supply, not otherwise specified (Medi-Cal)
In addition, payers usually require documentation [letter of medical necessity] from the clinician to support the need for the FARRELL Valve® System. Some payers utilize their own medical necessity form, therefore it is always best to confirm with the payer before submitting supporting documentation for payment.
Medicare does not currently allow the use of miscellaneous codes when billing for enteral nutrition.
Routine daily supplies for the delivery of enteral nutrition are identified in the following HCPCS codes:
- B4034: Enteral feeding supply kit; syringe feed, per day, includes but not limited to feeding/flushing syringe, administrative set tubing, dressing, tape
- B4035: Enteral feeding supply kit; pump feed, per day, includes but not limited to feeding/flushing syringe, administrative set tubing, dressing, tape
- B4036: Enteral feeding supply kit; gravity feed, per day, includes but not limited to feeding/flushing syringe, administrative set tubing, dressing, tape
The information provided should not be interpreted as a guarantee of reimbursement or endorsement by Medicare, Medicaid or private insurance plans. All medical necessity determination must be made by the responsible clinician (s) and any supporting documentation for claims must accurately represent the individual’s medical condition and circumstances.