Enteral Nutrition Pre-Pay Review Quarterly Status Report
Below is the analysis of claim denials for enteral nutrition HCPCS code B4035 reviewed between October 1 and December 31, 2023. The error rate for this quarter is 10.53%. The top 3 reasons for claim denials are as follows:
Rank | Reason | Percent |
---|---|---|
1. | The standard written order (SWO) is missing a description of the item. Refer to 42 CFR 410.38(d)(1), Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.2.2, and Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) | 33.33% |
2. | The medical record documentation does not provide justification for the use of a pump. | 33.33% |
3. | The 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 | 33.33% |
*The total percentage will be greater than 100% because some claims were 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 represent 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
Updated: February 2, 2024