Targeted Probe and Educate Round Results: Evaluation and Management Services – Initial 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 requirements were satisfied.
  • 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.
  • The provider indicated the service was billed in error.
  • Documentation submitted was for the incorrect date of service.
  • Documentation submitted indicated discrepancies between the performing and billing provider.
  • Documentation received referenced conflicting date of service/encounter date.
  • Documentation submitted was for the incorrect beneficiary
  • Documentation received referenced conflicting information regarding provider involvement.
  • Documentation submitted does not support the modifiers billed.
  • Documentation did not support a significant, separately identifiable E/M service distinct from other services.
  • Documentation was incomplete, lacked required elements, or did not include necessary progress notes.
  • Documentation did not support telehealth consent and/or modality (audio-only vs. audio/video).
  • Documentation submitted did not include a valid signature and/or credentials.
  • Documentation submitted was not legible.
  • Documentation submitted does not support reciprocal billing and fee-for-time compensation arrangements as indicated by the Q6 modifier.
  • Non-response to documentation request. 

Round results

CPT 99221

CPT 99222

CPT 99223

CPT 99232

CPT 99233