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Enteral Nutrition Pre-Pay Review Quarterly Status Report

Below is the analysis of claim denials for enteral nutrition HCPCS code B4035 reviewed between January 1 and March 31, 2024. The error rate for this quarter is 32.35%. The top five reasons for claim denials are as follows:

Rank Reason Percent
1. The medical record documentation does not establish that the beneficiary's condition is permanent. 33.33%
2. There is not a valid handwritten or electronic signature by the author of the medical record. 16.67%
3. The supplier shows the item(s) were billed in error. 16.67%
4. The documentation is incomplete. 16.67%
5. The medical record documentation does not provide justification for the use of a pump. 16.67%

*The total percentage will be greater than 100% because some claims denied for multiple reasons.

**The error rate included is an overall average for the supplier specific reviews as a part of the Targeted Probe and Educate program. This is not meant to be an overall error rate for the HCPCS code or policy under medical record review.

Resources:

Updated: May 21, 2024

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