Enteral Nutrition Quarterly Results of Targeted Probe and Educate Review - JA DME
Enteral Nutrition Quarterly Results of Targeted Probe and Educate Review
The Jurisdiction A, DME MAC, Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS code(s) B4034, B4150, B5152, B5153 and B4154. The quarterly edit effectiveness results from July 2024 - September 2024 are as follows:
Based on dollars, the overall claim potential improper payment rate is 39%.
Top Medical Necessity Denial Reasons
- Medical record documentation does not support enteral nutrition is required to maintain weight and strength commensurate with the beneficiary’s overall health status.
- Medical record documentation does not support either a full or partial non-function or disease of the structures that normally permit food to reach the small bowel; OR, disease that impairs digestion and/or absorption of an oral diet, directly or indirectly, by the small bowel.
- Medical record documentation does not support the treating practitioner’s judgement that the impairment will be of long and indefinite duration.
Top Technical Denial Reasons
- Documentation was not received in response to the Additional Documentation Request (ADR) letter.
- Claim is billed for greater quantity than the order indicates. Refer to Medicare Program Integrity Manual 5.9 and applicable Local Coverage Determination/Policy Article.
- Documentation does not include a standard written order (SWO). Refer to 42 CFR 410.38(d)(1), Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.2.1 & Standard Documentation Requirements A55426.
Educational Resources
Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the Enteral and Parenteral Nutrition webpage to access coverage documents (Local Coverage Determination (LCD), Policy Article, National Coverage Determination (NCD)); documentation letters, forms, and checklists; reviews; tips; tools; resources; related articles; and educational events and tutorials, if applicable.
See the CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3 information about probe/error validation reviews.
