June 14, 2023
Targeted Probe and Educate Update: September 2022 – March 2023
Effective September 1, 2021, the Centers for Medicare & Medicaid Services (CMS) resumed the Targeted Probe & Educate (TPE) process. The information below describes the TPE program's progress from September 2022 through March 2023.
Findings
Based on data analysis, Medical Review initiated complex review edits for specific providers that demonstrated a high risk for improper payment. CGS offered education throughout and upon completion of each round of TPE review. TPE results for Home Health and Hospice services are listed below.
Home Health Probes Completed
Current Edits
The primary focus of these reviews is to determine whether the medical record documentation supports the Medicare guidelines for medical necessity of the services billed. Current home health edits for TPE include:
Review Topic |
Edit Numbers |
Description |
Review Type |
---|---|---|---|
Medical Necessity |
5A007 5B007 5C007 |
This edit selects providers who submitted home health claims with 2 to 6 visits and diagnosis code I11.0, Z46.6, J44.1, I10, J44.9, G20, I25.10, N39.0, J18.9, or I87.2. |
TPE Prepayment Review |
New Providers |
5A006 5B006 5C006 |
This edit selects home health claims for relatively new providers who have submitted at least 50 claims. |
TPE Prepayment Review |
Medical Necessity |
5N000 5T000 5V000 |
This edit selects providers who submitted home health claims with 2 to 6 visits and diagnosis code I11.0, Z46.6, J44.1, I10, J44.9, G20, I25.10, N39.0, J18.9, or I87.2. |
TPE Round 1 Postpayment Round 2 Prepayment Round 3 Prepayment |
Results
Results |
5A006 Round 1 |
5A007 Round 1 |
5N000 Round 1 |
5B006 Round 2 |
5B007 Round 2 |
---|---|---|---|---|---|
# of Provider Probes Completed |
24 |
99 |
24 |
2 |
3 |
# of Compliant Providers |
1 |
2 |
4 |
1 |
0 |
# of Non-Compliant Providers |
23 |
97 |
20 |
1 |
3 |
# of Providers with Non-Responses to ADRs |
9 |
9 |
0 |
0 |
0 |
Education Contacts |
97 |
195 |
65 |
2 |
3 |
Findings by State
Summary of review findings for providers that completed rounds of review (by State):
Top Denial Reasons
- Skilled nursing not medically necessary (5HN18)
- Initial certification invalid (5HC09)
- FTF missing/incomplete/untimely (5HC01)
- Therapy visits not medically necessary (5HY01)
- Documentation does not support homebound (5HH01)
- Skilled nursing not medically necessary accounted for 25.86% of the total TPE denials.
- CGS Skilled Nursing in Home Health Care Web page
- Initial certification invalid accounted for 26.31% of the total TPE denials.
- FTF missing/incomplete/untimely accounted for 19.62% of the total TPE denials.
- The actual FTF encounter document was not submitted.
- CGS Home Health Face-to-Face (FTF) Encounter Web page
- The certifying physician did not document the date of the FTF encounter.
- The community physician was not identified when a physician who would not be following the patient after discharge signed the certification.
- No corroborating supporting documentation was incorporated.
- The required elements for initial certification (initial plan of care, initial certification, initial encounter documentation) were not submitted for recertification.
- CGS Home Health Coverage Guidelines Web page
- The actual FTF encounter document was not submitted.
- Therapy visits not medically necessary accounted for approximately 6.69% of the total TPE denials.
- CGS Physical Therapy Web page
- Documentation does not support homebound accounted for 6.69% of the total TPE denials.
- CGS Homebound Web page
Hospice Probes Completed
Current Edits
The primary focus of these reviews is to determine whether the medical record documentation supports the Medicare guidelines for medical necessity of the services billed. Current hospice edits for TPE include:
Review Topic |
Edit Numbers |
Description |
Review Type |
---|---|---|---|
LOS with Non-Oncologic Diagnosis |
5D000 5E000 5F000 |
This edit selects hospice providers who submitted claims for a length of stay (LOS) >730 days with a non-oncologic diagnosis code. |
TPE Prepayment Review |
GIP LOC |
5D006 5E006 5F006 |
This edit selects hospice providers who submitted claims with revenue code 0656 and units greater than or equal to 7 days. |
TPE Prepayment Review |
New Providers |
5D008 5E008 5F008 |
This edit selects hospice claims for relatively new providers who submitted at least 50 claims. |
TPE Prepayment Review |
LOS 313-515 days |
5D010 5E010 5F010 |
This edit selects hospice providers who submitted claims for a length of stay (LOS) 313-515 days. |
TPE Prepayment Review |
Results
Results |
5D000 Round 1 |
5D006 Round 1 |
5D008 Round 1 |
5D010 Round 1 |
---|---|---|---|---|
# of Provider Probes Completed |
7 |
5 |
20 |
10 |
# of Compliant Providers |
0 |
0 |
0 |
0 |
# of Non-Compliant Providers |
7 |
5 |
20 |
10 |
# of Providers with Non-Responses to ADRs |
0 |
0 |
1 |
2 |
Education Contacts |
15 |
21 |
71 |
21 |
Findings by State
Summary of review findings for providers that completed rounds of review (by State):
Top Denial Reasons
- Terminal prognosis not supported (5PM01)
- Notice of Election invalid (5PX06)
- NOE not present (5PX07)
- Certification missing (5PC02)
- Face-to-Face Encounter invalid (5PC08)
- Terminal prognosis not supported accounted for 48.28% of the total TPE denials.
- Notice of Election invalid accounted for 31.77% of the total TPE denials; NOE not present accounted for 4.59% of the total TPE denials.
- Certification missing accounted for 2.52% of the total TPE denials.
- CGS Hospice Certification / Recertification Requirements Web page
- Face-to-Face Encounter invalid accounted for approximately 2.29% of the total TPE denials.
Education
CGS offers providers with a moderate to high error rate an individualized education session in which each claim found in error is discussed and any questions answered. These education sessions may occur via webinar, web-based presentation, or traditional teleconference. Other methods may also be available. Providers may also submit questions or request education via email: J15HHPROBEANDEDUCATION@CGSADMIN.COM.
Next Steps
At the completion of Round 1/2, providers identified as non-compliant will advance to Round 2/3 of TPE at least 45 days from the 1:1 post-probe education call completion date. CGS offers provider education at any time, and you may request education even if you aren't selected for TPE. CGS encourages providers to request education, conduct self-monitoring based on our posted Medical Review Activity Log, and use tools such as Comparative Billing Reports (CBRs) offered through our myCGS web portal.