Enteral Nutrition Quarterly Results of TPE Review - JD DME

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 January 2025 – March 2025 are as follows:

Based on dollars, the overall claim potential improper payment rate is 30%.

Top Medical Necessity Denial Reasons

• 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.
• The quantity of enteral nutrition exceeds a 1-month supply.
• Enteral nutrition is non-covered for beneficiaries with temporary impairments.

Top Technical Denial Reasons

• Documentation was not received in response to the Additional Documentation Request (ADR) letter.

• Claim is billed for greater quantity than the order indicates.
• Standard written order (SWO) contains an error for a reason not otherwise specified.

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.