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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 1, 2024. The error rate for this quarter is 18.86%. The top nine reasons for claim denials are as follows:

Rank Reason Percent
1. The medical record documentation does not provide justification for the use of a pump. 35.71%
2. The standard written order (SWO) is missing a description of the item. 17.86%
3. The medical record documentation does not establish that the beneficiary's condition is permanent. 17.86%
4. The documentation does not have a valid Standard Written Order (SWO). 7.14%
5. Payment for supplies or items billed in excess of the quantity considered to be reasonable and necessary is being denied. 7.14%
6. There is not a valid handwritten or electronic signature by the author of the medical record. 3.57%
7. The medical record documentation is illegible. 3.57%
8. The claim is a duplicate. 3.57%
9. The medical record does not show an impairment as defined in the Enteral Nutrition – LCD (L38955)External Website and Enteral Nutrition – Policy Article (A58833)External Website. 3.57%

*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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