Medicare Qualification and Documentation Checklist for 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the date at the top of the form. Next, fill in the patient’s name, contact name, and contact phone number in the designated fields.
3. In the Orders/Script/Detailed Written Order section, ensure you gather necessary documentation from the physician regarding calorie intake and justification for tube feeding.
4. Check off the appropriate diagnosis that applies to the patient (Dysphagia, Obstruction, Malabsorption) and provide supporting medical records as required.
5. Complete the ICD-9 section by entering relevant codes based on provided diagnoses. Ensure all necessary documentation is attached.
6. For pump justification, check all applicable reasons for therapy needs such as reflux or aspiration. Provide additional notes if necessary.
7. If specialty formulas are needed, check one of the formula categories and provide any additional documentation required for reimbursement.

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