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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 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 5.2.2External PDF, and  Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website 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 210-212External PDF 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:

Updated: February 2, 2024

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