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)![]() ![]() |
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:
- Enteral Nutrition Documentation Checklist
- Enteral Nutrition – LCD (L38955)
- Enteral Nutrition – Policy Article (A58833)
- Enteral Nutrition Medical Review Resources
- Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
- Supplier Manual Chapter 3 – Supplier Documentation
Updated: May 21, 2024