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Enteral Nutrition Pre-Pay Review Quarterly Status Report

Below is the analysis of claim denials for enteral nutrition HCPCS code B43034 and B4035 reviewed July 1 – September 30, 2024. The error rate for this quarter is 20.77%. The top 10 reasons for claim denials are as follows:

Rank Reason Percent
1. The feeding supply kit does not correspond with the method of enteral nutrition administration. 23.94%
2. The standard written order is missing a description of the item. 15.49%
3. The medical record documentation does not justify for the use of a pump. 12.68%
4. The medical record documentation does not show that the beneficiary's condition is permanent. 12.68%
5. The medical record documentation does not document an impairment as defined in the local coverage determination or related policy article. 8.45%
6. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met. 5.63%
7. The documentation does not have a valid standard written order. 5.63%
8. Payment for supplies or items billed more than the quantity considered to be reasonable and necessary is being denied. 5.63%
9. We did not receive any medical record documentation. 4.23%
10. There is not a valid handwritten or electronic signature by the author of the medical record. 2.82%

*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: November 1, 2024

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