Targeted probe and educate (TPE) round results: Wound care (CPT 11042 and 11045)

Top denial / partial denial reasons and high-level results are listed below from each round of wound care 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. 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 did not support the treatment plan.
  • Documentation submitted did not support the procedure was done.
  • Documentation submitted lacked the patient's response to treatment plan.
  • Documentation submitted did not support the date service billed.
  • Documentation submitted did not specify the level of tissue debrided.
  • Documentation lacked a valid plan of care.
  • The provider indicated the service was billed in error. 

Round results