Targeted probe and educate (TPE) round results: Surgical services - nail cutting / pairing and debridement (CPT 11055-11057, 11719-11721 & HCPC G0127)
Top denial / partial denial reasons and high-level results are listed below from each round of nail cutting / pairing and debridement TPE reviews that have been conducted thus far by First Coast. 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. First Coast 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 was insufficient to support the services as billed.
- Documentation submitted did no support that the service was performed.
- Documentation submitted did not support an applicable class finding.
- Documentation submitted did not support the requirements outlined in the LCD.
- Non-response to documentation request.
Round results
