Results of Widespread Prepayment Review for
Enteral Nutrition Infusion Pump-Without Alarm (B9000) and
Enteral Nutrition Infusion Pump-With Alarm (B9002)
Historical Review Results
DME MAC JA Medical Review continues to review Enteral Nutrition Infusion Pump-Without Alarm (B9000) and Enteral Nutrition Infusion Pump-With Alarm (B9002, based on the results of the previous prepayment widespread review. The result of the total denied allowance amount (dollar amount of allowable charges for services determined to be billed in error) divided by the total allowance amount of services medically reviewed is the Charge Denial Rate (CDR). The previous review included claims reviewed August 01, 2015 - October 31, 2015, which resulted in 74.5% CDR.
Current Review Results
DME MAC JA has completed the widespread prepayment review of claims for B9002. These findings include claims processed primarily from November 1, 2015 thru January 31, 2016. The review involved prepayment complex medical review of 480 claims submitted by 93 suppliers. Responses to the Additional Documentation Request (ADR) were not received for 81 (17%) of the claims. For the remaining claims, 96 claims were allowed, and 303 were denied/partially denied resulting in a claim denial rate of 76% and a Charge Denial Rate of 72.1%.
Charge Denial Rate Historical Data
The following data depicts the Charge Denial Rate from previous quarters to current:
| Review Period | Charge Denial Rate |
| February 2015 - April 2015 | 78.4% |
| May 2015 - July 2015 | 73.9% |
| August 2015 - October 2015 | 74.5% |
| November 2015 - January 2016 | 72.1% |
Reasons for Denial
Based on review of the documentation received, the following are the primary reasons for denial. Note that the percentages noted below reflect the fact that a claim could have more than one missing/incomplete item. Also note that claims can be denied for multiple reasons therefore the percentages of reviews may not add up to 100%:
Clinical Documentation Issues (67%)
- 7% of the claims denied statutorily - did not meet prosthetic benefit requirement
- 3% of the denied claims did not have any medical record documentation submitted
- 20% of the denied claims did not have documentation to support specialty formula billed.
- 37% of the denied claims did not have documentation to support reasonable and necessary use of the enteral pump
Note: The criteria for enteral nutrition must first be met in order to allow consideration for payment of an enteral nutrition infusion pump.
Proof of Delivery Issues (43%)
- 16% of the denied claims had no Proof of Delivery (POD)
- 22% shipped either before or after the date of service of the claim when the item(s) is shipped via a shipping service or delivery service (Method II) directly to a beneficiary
- 5% of the denied claims were missing beneficiary (or designee) signature when item(s) are delivered directly by the supplier to the beneficiary
Detailed Written Order (DWO) Issues (38%)
- 4% The DWO did not include a detailed description of Detailed written order was missing a detailed description of the DME item(s) ordered B9002
- 15% The DWO was missing a physician signature and date of signature
- 6% The claim was missing a DWO
- 5% The claim was missing a detailed written order
- 8% The detailed written order was illegible
DME Information Form (DIF) (8%)
- 4% of the denied claims did not include a DME Informational Form
- 4% of the denied claims included a DIF that did not list the Enteral Pump HCPCS code
Claim Examples
As an additional educational measure, the following are actual examples of claim denials. NHIC expects these examples will assist suppliers in understanding the medical review process and the common documentation errors that occur with Enteral Nutrition Infusion Pump claims.
Example 1:
Received: Detailed written order, DME Information Form, Proof of Delivery
Missing: Illegible clinical documentation. Unable to determine reasonable and necessary for the specialty formula
Example 2:
Received: Detailed written order, Proof of Delivery
Missing: DME Information Form, clinical documentation to support the prosthetic benefit
Example 3:
Received: POD, clinical documentation establishing reasonable and necessary and coverage criteria
Missing: DME Information Form, Detailed written order
Next Step
Based on the results of this prepayment review, DME MAC JA will continue to review claims for B9000 and B9002.
DME MAC Jurisdiction A performs ongoing assessment of the effectiveness of its prepayment widespread reviews. One assessment is the Compliance Improvement Program (CIP), which measures suppliers' performance with providing complete and accurate supporting documentation and their response rate to Additional Documentation Requests (ADRs).
When a supplier achieves and maintains high quality accuracy and ADR response rate over three (3) quarterly periods, the supplier will be temporarily removed from that particular widespread review. The supplier's authorized official will be notified and provided details of this decision.
Questions and comments can be sent to the DME MAC Jurisdiction A Provider Compliance mailbox at: dme_mac_jurisdiction_a_provider_compliance@hpe.com
Educational References
NHIC provides extensive educational offerings related to the proper documentation requirements for enteral nutrition infusion pump claims. Please ensure that the responsible supplier staff is aware of and references this educational material so that supporting documentation for your claims is compliant with all requirements:
