Skip to Main Content

Print | Bookmark | Email | Font Size: + |

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)External Website and Enteral Nutrition – Policy Article (A58833)External Website. 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 5.9External PDF and Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website. 8.33%
6. No Medical record documentation was received. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.2.3.8External PDF 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:

Updated: February 2, 2024

spacer

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved