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:
- 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: November 5, 2024