Targeted probe and educate (TPE) round results: Evaluation and management services – emergency department 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 was reduced due to a change in rendering provider.
  • Documentation submitted was incomplete and/or insufficient to support the service billed.
  • Documentation submitted supported key elements and/or reasonable necessity of a lower level of service.
  • Non-response to documentation request. 

Round results