Targeted Probe and Educate (TPE) Ask-the-Contractor Teleconference (ACT)
View the handout for the March 29, 2018, Targeted Probe and Educate (TPE) Ask-the-Contractor Teleconference (ACT).
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- Are we allowed to bill for the claims that are under the TPE?
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Yes, continue to bill as usual.
Published: 04.18.18
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- Is the initial letter electronic?
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myCGS users and administrators will now see the TPE letters delivered to the "Messages" tab under your PTAN/NPI combination. To ensure you receive the notification, users and administrators will also be sent an email to the registered email address informing them of deliveries to the myCGS inbox.
Once you have successfully logged on to myCGS, a notification will display letting you know if you have any unread messages. To retrieve your messages select/click the Messages tab. Refer to the Attention myCGS Users: Targeted Probe and Educate (TPE) Notification and Results Letters Now Available in the myCGS Portal news article.
Published: 04.18.18
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- How far is the "look-back" review period for this TPE? (Ex: will CGS asks for a 2 year-old or more charts/DOS?)?
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Please refer to the TPE Notice Letter for the claim review from dates of service.
Published: 04.18.18
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- Is the TPE a pre-payment review?
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Please refer to the TPE Notice Letter for the type of review initiated, however, for home health and hospice currently all reviews are pre-payment reviews.
Published: 04.18.18
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- Our agency was part of round 1 and round 2 of the previous Face to Face probe. After the second round it was determined we were compliant and did not require further education. Is this a new effort of Probe & Educate or a continuation of the previous one? In either case, will agencies previously found compliant and therefore not in need of further education in the previous probe be exempt from this initiative?
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In 2014 CMS began a program that combined a review of a sample of claims with education to help reduce errors in the claims submission process; they called this medical review strategy, Probe and Educate. CMS believes results of this program have been favorable, based on the decrease in the number of claim errors after providers received education, so in August 2017, CMS announced expansion of this approach to targeted probe and education.
CGS selects providers for the TPE process based on the following:
- Analysis of billing data indicating aberrancies that may suggest questionable billing practices; or
- On targeted review and is transitioned to the TPE process based on error rate results; or
- On service specific review error rate results.
Published: 04.18.18
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- Does the actual date of the face to face encounter have to be on the 485's?
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The certifying physician must document the date of the face-to-face encounter. If the certifying physician has performed the face-to-face encounter, or has co-signed the face-to-face encounter documentation, then the date of the face-to-face does not need to be on the 485. If the above has not happened, then the date of the face-to-face encounter should be on the 485 to indicate the certifying physician has documented the date.
Published: 04.18.18
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- What is the time frame after you receive the "Notice of Review - Target Probe and Educate Review" letter, until you receive the ADR letters for the claims reviewed?
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A claim can be selected for ADR at any time after the Notice of Review letter is issued.
Published: 04.18.18
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- If the acute or post-acute medical record lacks details supporting homebound status, who does the home health agency send supporting documentation to?
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If the medical record discusses the homebound status, but does not give enough individual clinical information to support the homebound status, supporting documentation would be sent to the certifying physician to incorporate into his/her medical record for the patient. This is indicated by the certifying physician signing/dating the supporting documentation.
Published: 04.18.18
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- Is there a specific reason the GIP edit was changed from >5 days to >7 days?
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No specific reason.
Published: 04.18.18
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- Will the MAC's continue to receive incentive payment for finding errors/denials?
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We are unaware of any incentive payment for finding errors/denials for the MAC.
Published: 04.18.18
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- Will the providers who had no more than 1 probe issue in the last round and did not require further education be eliminated from the next round of probes?
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Providers are selected for Targeted Probe and Educate based on ongoing data analysis and can be selected at any given point in time. No provider is currently "eliminated" from Targeted Probe and Educate.
Published: 04.18.18
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- How often do the edits change?
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Please refer to the Medical Review Activity Log to check for the current edits in place for Home Health and Hospice. You are encouraged to sign up for the CGS ListServ to receive announcement updates. Visit the CGS ListServ Notification Service Web page to subscribe.
Published: 04.18.18
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- Will rehabilitation facility therapy documentation from the early part of a 30 day rehab stay be considered in supporting homebound status and the need for skilled services for a home health episode started after discharge from the facility?
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If the documentation is indicative of the patient's status when the patient is admitted to home health it would be considered. However, if the patient has changed significantly from then, you would need further documentation to indicate the patient's current status at the time of home health admission.
Published: 04.18.18
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- If the F2F has not happened at the time the POC is completed, is it acceptable to send a certification statement with the F2F date to the certifying physician for signature?
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The face-to-face encounter must be completed prior to the certifying physician signing the certification.
Published: 04.18.18
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- If 20-40 claims are needed for TPE and the agency does not have that level of volume on a monthly basis for claim submissions - how does that work? Will the agency have all claims submitted over a period of 2-3 months until the minimum 20 claims are reached?
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Claims will be sampled until the minimum 20 to maximum of 40 claim sample is achieved. Agency billing volume will be a factor in how quickly a sample can be completed.
Published: 04.18.18
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- In the event there is no LCD for the TPE topic being reviewed, where should the provider go for guidance/documentation requirements?
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The LCDs are used as a guide only. Check the CGS website for further assistance in completing documentation appropriately. The following links may be of assistance for help in complete documentation. Even though they are titled as hospice, they are useful for home health also.
Published: 04.xx.18
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- Is there a specific error rate per round that indicates a provider will advance to the next round?
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Please refer to the Targeted Probe and Educate Notice letter for the error rate required for discontinuation.
Published: 04.18.18
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- If I received a TPE letter that did not contain an error rate, can I call CGS for additional information?
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Feel free to contact us at the J15HHPROBEANDEDUCATION@CGSADMIN.COM mailbox and we will be happy to assist if the notice letter did not contain an error rate.
Published: 04.18.18
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- Do the approved appeals of ADR's sent count against your 25% denial if these are paid?
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The appeals process does not bear change on the error rate calculated from the initial ADR Medical Review determination.
Published: 04.18.18
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- If the F2F documentation (MD visit note) does not list homebound information, does the homebound statement on the 485 that is signed by the certifying physician cover that requirement?
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The individual clinical information for homebound status must be addressed in the face-to-face documentation. If it is not complete, supporting documentation may be provided to the certifying physician to be signed/date and included in the physician's medical record for that patient.
Published: 04.18.18
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- Will there be further analysis of claims to target providers going forward or is the July-September 2017 the only data that is being used?
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Providers are selected for Targeted Probe and Educate based on ongoing data analysis and can be selected at any given point in time based on analysis of billing data indicating aberrancies that may suggest questionable billing practices.
Published: 04.18.18
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- When will the letters for this TPE be going out?
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Some provider letters have already been issued and will continue to be issued based on data analysis.
Published: 04.18.18
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- Upon preparing the ADR for review, is it acceptable to number the pages and create an outline?
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Yes, that is acceptable.
Published: 04.18.18
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- If the F2F documentation of the encounter is only accepted prior to the certification being signed, why is the F2F regulation state that you have 30 days after the start of care to have the documentation take place?
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The signing of the certification needs to wait until after the completion of the face-to-face encounter. The encounter may take place up to 30 days after the start of care. The certification would not be completed until after the face-to-face encounter is completed, even if it is 30 days after the start of care. In some states, the state regulations may say the certification needs to be signed before 30 days have elapsed since the start of care. In that case, the face-to-face still needs to be signed prior to the certification, but you may not have the full 30 days after the state of care if that is what the state regulation states.
Published: 04.18.18
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