Targeted probe and educate (TPE) round results: Evaluation and management services – initial inpatient care visits and subsequent inpatient care visits

Top denial / partial denial reasons and high-level results are listed below from each round of evaluation and management (E/M) services TPE reviews that have been conducted thus far by Medical Review. If you have questions about your individual results, please contact the nurse reviewer assigned to your review for additional information. Additional rounds of review will be utilized when the targeted topic demonstrates a continued need for review with newly identified providers.

Top denial / partial denial reasons

The most common reasons for denial or partial denials are the following:

• Medical necessity – The documentation submitted does not support medical necessity as listed in coverage requirements.
• Insufficient documentation – Insufficient documentation was provided to support the services as billed to Medicare. Medical Review makes multiple attempts to correct these error types before completion of the review. Below are the following denial reasons for insufficient documentation that we were not able to resolve:
  • Documentation submitted did not support split / shared service criteria met.
  • Documentation submitted did not support the billing of service as “incident to” a physician.
  • Documentation submitted did not support a significant, separately identifiable E/M.
  • Documentation submitted for review did not support the billed date of service.
  • Documentation submitted lacked the key elements to support the level of service billed.
  • Documentation submitted was reduced due to a change in rendering provider.
  • Documentation submitted supported key elements and/or reasonable necessity of a lower level of service.
  • Documentation submitted does not support a separate E&M service was performed during a global period.
  • Documentation submitted did not support the direct supervision requirement to meet teaching service criteria.
  • Documentation submitted supported the key elements and/or reasonable necessity of a higher level of service.
  • Documentation submitted did not support a covered Medicare benefit.
  • Service billed in error.
  • Non-response to documentation request. 

Round results

CPT 99223

CPT 99232