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October 31, 2019

Targeted Probe and Educate Progress Update

The Centers for Medicare & Medicaid Services (CMS) Change Request 10249 implemented the Targeted Probe & Educate (TPE) process, effective October 1, 2017. The following provides progress of TPE from October 1, 2017 – September 30, 2019.

Findings

Medical Review initiated complex review edits for specific providers identified through data analysis demonstrating high risk for improper payment. Education has been offered to providers throughout and upon completion of each Round of TPE review. Current TPE Home Health and Hospice Results are as follows:

Home Health

Probes completed October 1, 2017 – September 30, 2019

Eligibility and Medical Necessity edit

Results	5A000 Round 1	5B000 Round 2	5C000 Round 3
Probes Completed	388	158	1
Providers Compliant after Round Completion	51	66	0
Providers Non-compliant after Round Completion (advancing)	337	92	1
Providers with Non-Reponses to ADRs for Round	80	16	0

LOS >120 Days edit

Results	5A002 Round 1	5B002 Round 2	5C002 Round 3
Probes Completed	1	0	0
Providers Compliant after Round Completion	0	0	0
Providers Non-compliant after Round Completion (advancing)	1	0	0
Providers with Non-Reponses to ADRs for Round	0	0	0

LOS >180 Days edit

Results	5A003 Round 1	5B003 Round 2	5C003 Round 3
Probes Completed	1	0	0
Providers Compliant after Round Completion	0	0	0
Providers Non-compliant after Round Completion (advancing)	1	0	0
Providers with Non-Reponses to ADRs for Round	1	0	0

No response to ADR edit

Results	5A004 Round 1	5B004 Round 2
Probes Completed	65	22
Providers Compliant after Round Completion	5	12
Providers Non-compliant after Round Completion (advancing)	60	10
Providers with Non-Reponses to ADRs for Round	30	2

Low Visit Utilization edit

Results	5A005 Round 1	5B005 Round 2	5C005 Round 3
Probes Completed	10	0	0
Providers Compliant after Round Completion	4	0	0
Providers Non-compliant after Round Completion (advancing)	6	0	0
Providers with Non-Reponses to ADRs for Round	2	0	0

Findings by State

CGS is providing an overview of review findings by state for providers who have completed Rounds.

Review decisions by state

Top Denial Reasons October 1, 2017 – September 30, 2019

Face-to-Face missing/incomplete/untimely
Initial certification invalid
Therapy visits not medically necessary
Recert estimate missing/invalid
Plan of Care missing/invalid
- FTF Documentation Denials accounted for approximately 28% of the total Targeted Probe and Educate denials.
  - Actual FTF encounter document not submitted
    - CGS Home Health Face-to-Face (FTF) Encounter Web page
  - Certifying physician did not document the date of the FTF encounter
    - CGS Home Health Physician Certification Web page
  - Community physician was not identified when a physician who would not be following the patient after discharge signed the certification
  - No corroborating supporting documentation incorporated
    - CGS Incorporating Home Health Agency Documentation into the Physician's Medical Record: Supporting Eligibility with Home Health Agency Clinician Notes Web page
  - Required elements for initial certification (initial plan of care, initial certification, initial encounter documentation) were not submitted for recertification
  - Refer to the CGS Home Health Coverage Guidelines Web page for a variety of resources on the home health FTF encounter.
- Initial Certification Denials accounted for approximately 13% of the total Targeted Probe and Educate denials.
  
  Refer to the CGS Home Health Physician Certification Web page for documentation tips and access to the Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 7).
- Documentation did not support medical necessity of therapy services accounted for approximately 8% of the total Targeted Probe and Educate denials.
  
  Refer to the CGS Physical Therapy Web page for documentation tips, access to the Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 7) therapy information and the Local Coverage Determination for physical therapy services.
- Recertification estimate missing/invalid accounted for approximately 6% of the total Targeted Probe and Educate denials.
- Dates of Service before January 1, 2019. The physician's estimate of how much longer skilled services will be required
  
  · Is the physician's estimate stated in a measurable unit of time (i.e. days, weeks, months, years)?
- Refer to the CGS Home Health Physician Recertification Estimate Tip Web page for documentation tips, access to the Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 7).
- Plan of care missing/invalid accounted for approximately 6% of the total Targeted Probe and Educate denials.

Refer to the CGS Physician Orders, Plan of Care and Certification and Home Health Missing/Incomplete/Untimely Plan of Care or Certification Web pages for documentation tips and access to the Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 7).

Hospice

Probes completed October 1, 2017 – September 30, 2019

LOS with Non-Oncologic Diagnosis edit

Results	5D000 Round 1	5E000 Round 2
Probes Completed	31	3
Providers Compliant after Round Completion	9	1
Providers Non-compliant after Round Completion (advancing)	22	2
Providers with Non-Reponses to ADRs for Round	5	0

LOS >180 Days edit

Results	5D002 5D007 Round 1	5E002 5E007 Round 2
Probes Completed	2	1
Providers Compliant after Round Completion	1	1
Providers Non-compliant after Round Completion (advancing)	1	0
Providers with Non-Reponses to ADRs for Round	0	0

LOS >120 Days edit

Results	5D003 Round 1	5E003 Round 2	5F003 Round 3
Probes Completed	1	0	0
Providers Compliant after Round Completion	0	0	0
Providers Non-compliant after Round Completion (advancing)	1	0	0
Providers with Non-Reponses to ADRs for Round	0	0	0

LOS in LTC, NF or SNF edit

Results	5D004 Round 1	5E004 Round 2
Probes Completed	1	1
Providers Compliant after Round Completion	0	1
Providers Non-compliant after Round Completion (advancing)	1	0
Providers with Non-Reponses to ADRs for Round	0	0

GIP LOC edit

Results	5D006 Round 1	5E006 Round 2	5F006 Round 3
Probes Completed	6	0	0
Providers Compliant after Round Completion	3	0	0
Providers Non-compliant after Round Completion (advancing)	3	0	0
Providers with Non-Reponses to ADRs for Round	0	0	0

Findings by State

CGS is providing an overview of review findings by state for providers who have completed Rounds.

Review decisions by state

Top Denial Reasons October 1, 2017 – September 30, 2019

Terminal prognosis not supported
Face-to-Face Encounter invalid
Hospice plan of care invalid
- Terminal prognosis not supported accounted for approximately 69% of the total Targeted Probe and Educate denials.
  
  Refer to the CGS Hospice Denial Fact Sheet—Six-Month Terminal Prognosis Not Supported Web page for documentation tips and access to the Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 9).
- Face-to-Face Encounter Denials accounted for approximately 7% of the total Targeted Probe and Educate denials.
  
  Refer to the CGS Hospice Face-to-Face (FTF) Encounter and Hospice Denial Fact Sheet – Face-to-Face Encounter is Missing/Incomplete/Untimely Web pages for documentation tips and access to the Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 9).
- Hospice plan of care invalid accounted for approximately 6% of the total Targeted Probe and Educate denials.

Refer to the CGS Hospice Plan of Care and Hospice Denial Fact Sheet – Plan of Care Web pages for documentation tips and access to the Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 9).

Education

Providers with a moderate to high error rate will be offered an individualized education session where each claim found in error will be discussed and any questions will be answered. CGS offers education sessions via webinar, web-based presentation, or traditional teleconferences. Other methods may also be available. Providers may also submit questions or request education via the home health and hospice TPE email box at J15HHPROBEANDEDUCATION@CGSADMIN.COM.

Next Steps

Providers found to be non-compliant at the completion of Round 1/2 will advance to Round 2/3 of TPE at least 45 days from completion of the 1:1 post probe education call date. CGS offers education at any time for providers. Providers do not have to be identified for TPE to request education. CGS encourages providers to request education and conduct self-monitoring based on our posted Medical Review Activity Log and using tools such as Comparative Billing Reports (CBRs) offered through our web portal.

References

CMS Targeted Probe and Educate (TPE) Web Page
Change Request 10249
CGS HHH Educational Materials and Resources Web page
CGS Medical Review Additional Development Request (ADR) Process Web page

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

AMA Disclaimer of Warranties and Liabilities.

CMS Disclaimer

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

Targeted Probe and Educate Progress Update

Home Health

Probes completed October 1, 2017 – September 30, 2019

Eligibility and Medical Necessity edit

LOS >120 Days edit

LOS >180 Days edit

No response to ADR edit

Low Visit Utilization edit

Findings by State

Hospice

Probes completed October 1, 2017 – September 30, 2019

LOS with Non-Oncologic Diagnosis edit

LOS >180 Days edit

LOS >120 Days edit

LOS in LTC, NF or SNF edit

GIP LOC edit

Findings by State

Top Denial Reasons October 1, 2017 – September 30, 2019

Education

Next Steps

References

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