Pre-Payment Review Results for Established Patient Office Visit for January to March 2025

Published 05/13/2025

Pre-Payment Review Results for Evaluation and Management (E/M): Current Procedural Terminology® (CPT®) Codes 99213–99215 Established Patient Office Visit for Targeted Probe and Educate (TPE) for January to March 2025

The Centers for Medicare & Medicaid Services (CMS) implemented the TPE process for CPT® codes 99213–99215 Established Patient Office Visit. The reviews with edit effectiveness are presented here for North Carolina, South Carolina, Virginia and West Virginia.

Cumulative Results

Table 1. Cumulative Results.
Number of Providers with Edit Effectiveness Providers Compliant Completed/Removed After Probe Providers Non-Compliant Progressing to Subsequent Probe Providers Non-Compliant/Removed for Other Reason
33 15 18 0
Table 2. Cumulative Results.
Number of Claims with Edit Effectiveness Number of Claims Denied Overall Claim Denial Rate Total Dollars Reviewed Total Dollars Denied Overall Charge Denial Rate
658 249 38% $90,454.27 $22,148.66 24%

Probe One Findings

Table 3. Probe One Findings.
State Number of Providers with Edit Effectiveness Providers Compliant Completed/Removed After Probe Providers Non-Compliant Progressing to Subsequent Probe Providers Non-Compliant/Removed for Other Reason
N.C. 33 15 18 0
S.C. 0 0 0 0
Va. 0 0 0 0
W.Va. 0 0 0 0
Table 4. Probe One Findings.
State Number of Claims with Edit Effectiveness Number of Claims Denied Overall Claim Denial Rate Total Dollars Reviewed Total Dollars Denied Overall Charge Denial Rate
N.C. 658 249 38% $90,454.27 $22,148.66 24%
S.C. 0 0 0% $0.00 $0.00 0%
Va. 0 0 0% $0.00 $0.00 0%
W.Va. 0 0 0% $0.00 $0.00 0%

Risk Category

The categories for CPT® codes 99213–99215 Established Patient Office Visit are defined as:

Table 5. Risk Category.
Risk Category Error Rate
Minor 0–20%
Major 21–100%

Figure 1. Risk Category for Established Patient Office Visit CPT® Codes 99213–99215.

Pie chart showing 45% minor and 55% major.

Top Denial Reasons

Table 6. Top Denial Reasons.
Percent of Total Denials Denial Code Denial Description Number of Occurrences
47% DOWNC Payer Deems the Information Submitted Does Not Support this Level of Service; Downcoded 16
29% NODOC Documentation Requested for this Date of Service Was Not Received or Was Incomplete; Therefore We Are Unable to Make a Reasonable and Necessary Determination as Defined Under Section 1862(a) (1) (A) of the ACT for the Service Billed, and this Service Has Been Denied 10
6% NOTMN Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed 2
3% WRONG Documentation Received Contains an Incorrect, Incomplete or Illegible Patient Identification or Date of Service 1
3% UPCODE Payer Deems the Information Submitted Does Not Support This Level of Service; Upcoded 1

Denial Reasons and Recommendations

DOWNC — Payer Deems the Information Submitted Does Not Support this Level of Service; Downcoded

NODOC — Documentation Requested for this Date of Service Was Not Received or Was Incomplete; Therefore We Are Unable to Make a Reasonable and Necessary Determination as Defined Under Section 1862(a) (1) (A) of the ACT for the Service Billed, and this Service Has Been Denied

  • Submit all documentation related to the services billed within 45 days of the date on the Additional Documentation Request letter
  • Review documentation prior to submission to ensure that the documentation is complete and that all dates of service requested are included
  • Include any additional information pertinent to the date of service requested to support the services billed. For example: original chart notes, diagnostic, radiological or laboratory results.
  • For claims denied with a M127 or N29 code listed on the remittance advice, be sure to submit all documentation for all dates of service on that claim with a reopen/redetermination request form by fax to Jurisdiction M Part B (803) 699–2427, Jurisdiction J Part B (803) 870–0139 or Railroad Beneficiaries Appeals (803) 462–2218
     

NOTMN — Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed

  • Ensure that all documentation to support medical necessity of the service billed is submitted for review. This includes original chart notes and any diagnostic, radiological or laboratory results.
  • Verify that documentation to support the level of service billed is included. Please refer to the Palmetto GBA website for applicable LCDs, NCDs and the E/M Scoresheet Tool for documentation requirements.
     

WRONG — Documentation Received Contains an Incorrect, Incomplete or Illegible Patient Identification or Date of Service

  • Review all documentation prior to submission to ensure that it is for the correct patient and date of service
  • Ensure that patient identifiers are legible and complete
  • Ensure that the complete date of service is clearly and legibly noted on all documentation
  • Prior to billing claims, review the information to determine that the correct patient identifier and the correct date of service are listed in the appropriate field
     

UPCODE — Payer Deems the Information Submitted Does Not Support This Level of Service; Upcoded

  • Ensure that all documentation to support the level of service billed is submitted for review
  • Verify that documentation to support the level of service billed is included. Please refer to the Palmetto GBA website for applicable LCDs, NCDs and the E/M Scoresheet Tool for documentation requirements.
     

Education
Palmetto GBA offers providers selected for TPE an individualized education session to discuss each claim denial. This is an opportunity to learn how to identify and correct claim errors. A variety of education methods are offered such as webinar sessions, web-based presentations or teleconferences. Other education methods may also be available. Providers do not have to be selected for TPE to request education. If education is desired, please complete the Education Request Form (PDF).

Next Steps
Providers found to be non-compliant (major risk category/denial rate of 21–100 percent) at the completion of TPE Probe 1 will advance to Probe 2, and providers found to be non-compliant (major risk category/denial rate of 21–100 percent) at the completion of TPE Probe 2 will advance to Probe 3 of TPE after at least 45 days from completing the 1:1 post-probe education call date.


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