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August 13, 2019

J15 Targeted Probe and Educate Status Update

The J15 Part A Medical Review department initiated probe review edits for specific providers in Kentucky and Ohio identified through data analysis as demonstrating high risk for improper payment. Education has been offered to providers throughout, and upon completion of, Round 1 and Round 2 of the Targeted Probe and Educate (TPE) process.

This chart reflects probes completed between April 1, 2019–June 30, 2019

The results of the probes per edit are listed below for the period of April 2019 – June 2019:

5PE13 Round 1 Review of SNF RUG Codes RUA, RUB, RUC, RUL,RUX, RVA, RVB, RVC, RVL and RVX

Overall Claim Findings by State

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How to Prevent Denials:

Documentation to Include:

  • Completed Certification/Recertification inclusive of an estimation of how much time is required for skilled services signed and dated by physician or approved healthcare professional
  • Therapy minutes and daily progress notes supporting RUG code for dos billed, including rolling 7 day period, and any “change of therapy” periods
  • Interdisciplinary orders and evaluations
  • SNF Minimum Data Set (MDS) in the national repository

    MCR Benefit Policy Manual 100-2, Chapter 8 SNFExternal PDF

    MLN SNF Billing ReferenceExternal PDF

5PE14 Round 1 Review of IRF CMGs 0110, 0704, 2004, 0604, 2003, 0304, 0603, 0904, 1003, and 0506

Overall Claim Findings by State

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How to Prevent Denials:

Documentation to Include:

5PE16 Round 1 Review of Outpatient Claims for Pulmonary Rehabilitation (HCPCS G0424)

Overall Claim Findings by State

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How to Prevent Denials:

Documentation to Include:

5PE17 Round 1 Review of Inpatient Spinal Fusion Claims (DRGs 456, 457, 458, 459, and 460)

Overall Claim Findings by State

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How to Prevent Denials:

Documentation to Include:

To learn more about the Targeted Probe & Education process, please refer to the following links:

Please submit all documentation as required in the LCD or NCD if applicable and in accordance with the Medicare Benefit Policy Manual. It is the responsibility of the provider to submit complete and accurate documentation per the regulatory guidelines for each claim. In order to meet the policy requirements for each claim submitted, please refer to ADR (Additional Documentation Request) received and visit the links provided for additional information specific to each edit.

Next Steps:

Providers found to be non-compliant at the completion of Round 1/2 will advance to Round 2/3 of TPE within 45 days of completion of the post probe educational session. CGS offers education at any time for providers regardless of identification for TPE. Part A Providers may submit questions or request education via the Part A TPE email box (Please include the facility name and Provider Number/PTAN in the subject of the email): J15AprobeandEducation@cgsadmin.com

CGS encourages providers to request education and conduct self-monitoring based on our posted Medical Review activity and using tools such as Comparative Billing Reports (CBRs) offered through our web portal.

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