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 January 2024 - March 2024 are as follows:
Based on dollars, the overall claim potential improper payment rate is 27%.
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 judgment that the impairment will not be of long and indefinite duration.
Top Technical Denial Reasons
- No medical record documentation was received.
- Claim is billed for greater quantity than the order indicates.
- Documentation does not include a 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.
