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:
- Enteral Nutrition Documentation Checklist
- Enteral Nutrition – LCD (L38955)
- Enteral Nutrition – Policy Article (A58833)
- Enteral Nutrition Medical Review Resources
- Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
- Supplier Manual Chapter 3 – Supplier Documentation
Updated: May 21, 2024