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 1, 2023. The error rate for this quarter is 24.32%. The top 6 reasons for claim denials are as follows:
Rank | Reason | Percent |
---|---|---|
1. | The medical record documentation does not document an impairment as defined in the Enteral Nutrition – LCD (L38955) and Enteral Nutrition – Policy Article (A58833). | 33.33% |
2. | The medical record documentation does not establish that the beneficiary's condition is permanent. | 25.00% |
3. | The medical record documentation does not provide justification for the use of a pump. | 16.67% |
4. | The documentation submitted is incomplete | 8.33% |
5. | The medical record documentation is dated after the date of service. Refer to Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.9 and Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426). | 8.33% |
6. | No Medical record documentation was received. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.2.3.8 | 8.33% |
*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