Parenteral Nutrition Quarterly Results of Targeted Probe and Educate Review - JA DME

The Jurisdiction A, DME MAC, Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS code(s) B4185, B4193, B4197, and B4199 as well as any additional codes on the claim for the related policy. The quarterly edit effectiveness results from October 2025 - December 2025 are as follows:

Based on dollars, the overall claim potential improper payment rate is 6%.

Top Medical Necessity Denial Reasons

• The medical record documentation of the treating practitioner does not demonstrate that enteral nutrition has been considered and ruled out, tried, and been found ineffective, or that enteral nutrition exacerbates gastrointestinal tract dysfunction.
• Related item denied due to medical necessity.
• The treating practitioner's order, certificate of medical necessity, supplier prepared statement, or the practitioner's attestation, by itself, does not provide sufficient documentation of medical necessity.

Top Technical Denial Reasons

• Documentation was not received in response to the Additional Documentation Request (ADR) letter.
• Related item denied due to invalid Standard Written Order (SWO).
• 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.

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.