Parenteral Nutrition Quarterly Results of Targeted Probe and Educate Review - JA DME
Parenteral 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) B4185, B4193, B4197 and B4199. The quarterly edit effectiveness results from July 2024 - September 2024 are as follows:
Based on dollars, the overall claim potential improper payment rate is 16%.
Top Medical Necessity Denial Reasons
- 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 EN exacerbates gastrointestinal tract dysfunction.
- Medical record documentation does not demonstrate the beneficiary has a permanent, severe pathology of the alimentary tract which does not allow absorption of sufficient nutrients to maintain weight and strength commensurate with the beneficiary’s general condition.
- 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.
Top Technical Denial Reasons
- 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.
- Documentation does not include a standard written order (SWO). Refer to 42 CFR 410.38(d)(1), Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.2.1 & Standard Documentation Requirements A55426.
- Claim submitted is a duplicate to another claim billed.
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.
