Enteral Nutrition Quarterly Results of TPE Review - JD DME
Enteral Nutrition Quarterly Results of Targeted Probe and Educate Review
The Jurisdiction D, DME MAC, Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS code(s) B4150, B4152 and B4154. The quarterly edit effectiveness results from April 2025 - June 2025 are as follows:
Based on dollars, the overall claim potential improper payment rate is 22%.
Top Medical Necessity Denial Reasons
- Medical record documentation does not support the treating practitioner’s judgement that the impairment will be of long and indefinite duration.
- 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.
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.
- Standard written order (SWO) does not specify the type of supplies needed in such a manner that the supplier may calculate the necessary disbursement and assess the continued need for refill with the beneficiary. Refer to Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.11.
- Related item denied: Order
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.
