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) B4150, B5152, B5153, and B4154 as well as any additional codes on the claim for the related policy. The quarterly edit effectiveness results from July 2025 - September 2025 are as follows:

Based on dollars, the overall claim potential improper payment rate is 10%.

Top Medical Necessity Denial Reasons

  • The medical record documentation does not support the treating practitioner’s judgement that the impairment will be of long and indefinite duration.
  • The medical record documentation does not support enteral nutrition is required to maintain weight and strength commensurate with the beneficiary’s overall health status.
  • The quantity of enteral nutrition exceeds a 1-month supply.

Top Technical Denial Reasons

  • The 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.
  • No medical record documentation was received. Refer to Medicare Program Integrity Manual 3.2.3.8.
  • Related item denied due to invalid Standard Written Order (SWO).

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.

Last Updated Oct 28 , 2025