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. The quarterly edit effectiveness results from January 2024 - March 2024 are as follows:

Based on dollars, the overall claim potential improper payment rate is 58%.

Top Medical Necessity Denial Reasons

• Medical record documentation does not demonstrate the beneficiary has a) a condition involving the small intestine and/or its exocrine glands which significantly impairs the absorption of nutrients or b) disease of the stomach and/or intestine which is a motility disorder and impairs the ability of nutrients to be transported through the GI system.
• 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.
• Medical record documentation does not demonstrate the beneficiary has a permanent impairment that will be of long and indefinite duration.

Top Technical Denial Reasons

• Documentation does not include a standard written order (SWO).
• No medical record documentation was received.
• Claim is billed for greater quantity than the order indicates.

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.