The Jurisdiction D, DME MAC, Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS codes B4150, B4152, B4154. The quarterly edit effectiveness results from April 2023 - June 2023 are as follows:

Based on dollars, the overall claim potential improper payment rate is 13%.

Top Medical Necessity Denial Reasons

• The quantity of enteral nutrition exceeds a 1-month supply.

Top Technical Denial Reasons

• Documentation was not received in response to the Additional Documentation Request (ADR) letter.
• 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.
• The medical record documentation contains an error 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.