Medicare Critical Care and Initial Hospital Services E and M Slated for Review
By Ellen Terry


If you’ve been “probed and educated” twice by Novitas Solutions Inc. for high rate of claims errors regarding certain evaluation and management (E&M) services, you may receive more such review and education this summer. 

Claims for E&M for initial hospital services and for critical care services will be the target of improper Medicare payment review starting in June and August respectively, when Novitas begins round three of claim reviews under the Centers for Medicare & Medicaid Services (CMS) Targeted Probe and Educate (TPE) program. 

Physicians with continued high error rates after three rounds of review and education may be referred to CMS for additional action, such as 100% prepayment review, extrapolation (using a statistical sample of the physician’s claims to determine overpayments), or referral to a Recovery Audit Program contractor. 

CMS says some common claim errors are:

  • The signature of the certifying physician was missing.
  • Encounter notes did not support all elements of eligibility.
  • Documentation does not meet medical necessity. 

Novitas publishes checklists for responding to TPE reviews, including: 

More information on the Targeted Probe and Educate program is on the Novitas Solutions website and this CMS flyer

If you have questions about billing and coding or payer policies, TMA’s reimbursement specialists can help. Email questions to paymentadvocacy[at]texmed[dot]org, or call the TMA Knowledge Center at (800) 880-7955. Or turn to TMA Practice Consulting for an in-depth review of your documentation and claims coding that could identify deficiencies and areas of risk for an audit. Contact a consultant at (800) 523-8776 or[at]texmed[dot]org.

Last Updated On

May 17, 2019

Originally Published On

May 16, 2019

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Ellen Terry

Project Manager, Client Services

(512) 370-1391

Ellen Terry has been writing, editing, and managing communication projects at TMA since 2000. She hails from Victoria, Texas; has a journalism degree from Texas State University; and loves to read great fiction. Ellen and her husband have two grown sons and a couple of cats.

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