Enteral Nutrition - Targeted Probe and Educate Results

The Jurisdiction A, DME MAC, Medical Review Department conducted 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 show the overall claim potential improper payment rate is 39%. The top medical necessity denial reasons include:

  • 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.

Refer to the Medical Record Review Results page for more information.

Last Updated Feb 06 , 2025