Parenteral Nutrition Quarterly Results of TPE Review - JD DME
Parenteral 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) B4185, B4193, B4197 and B4199. The quarterly edit effectiveness results from October 2024 – December 2024 are as follows:
Based on dollars, the overall claim potential improper payment rate is 15%.
Top Medical Necessity Denial Reasons
- Medical record documentation does not demonstrate the beneficiary has a permanent impairment that will be of long and indefinite duration.
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 was not received in response to the Additional Documentation Request (ADR) letter.
- Beneficiary was in an acute care hospital or skilled nursing facility on this date of service. Refer to Medicare Claims Processing Manual 100-04, Chapter 20, Sections 210-212.
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.
