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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 July 1 – September 30, 2024. The error rate for this quarter is 12.27%. The top 8 reasons for claim denials are as follows:

Rank Reason Percent
1. Payment for supplies or items billed in excess of the quantity considered to be reasonable and necessary is being denied. 22.00%
2. The feeding supply kit does not correspond with the method of enteral nutrition administration. 18.00%
3. The documentation does not have a valid order. 16.00%
4. The claim is billed for greater quantity than the order shows. 16.00%
5. The standard written order (SWO) is missing a description of the item. 14.00%
6. The medical records received lack sufficient information concerning the beneficiary’s condition to determine if medical necessity coverage criteria were met. 8.00%
7. No Medical record documentation was received. 4.00%
8. The medical record documentation does not show that the beneficiary’s condition is permanent. 2.00%

*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 5, 2024

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