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 January 2025 – March 2025 are as follows:
Based on dollars, the overall claim potential improper payment rate is 15%.
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 treating practitioner evaluated the beneficiary within 30 days prior to the initiation of parenteral nutrition.
- Medical record documentation does not demonstrate the reason why the beneficiary was not evaluated within 30 days prior to initial certification and what other monitoring methods were used to evaluate the beneficiary’s enteral nutrition needs.
Top Technical Denial Reasons
- Claim is billed for greater quantity than the order indicates.
- Related item denied: Order
- Documentation was not received in response to the Additional Documentation Request (ADR) letter.
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.
