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Quarterly TPE Update July 2019 – September 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 July 1, 2019 – September 30, 2019:

Results Kentucky Ohio
Probes Completed 7 19
Providers Compliant after Round 1 Completion 6 17
Providers Non-compliant after Round 1 Completion 1 2
Providers with Non-Reponses to ADR's for Round 1 0 7

The results of the probes per edit are listed below for the period of July 1, 2019 – September 30, 2019:

5PE11 Round 1 Spinal Injections/Epidural Steroid Injections (ESI) (HCPCS code 62323)

  Kentucky Ohio
Probes Completed 1 2
Providers Compliant after Round 1 Completion 0 2
Providers Non-compliant after Round 1 Completion 1 0
Providers with Non-responses to ADR's for Round 1 0 0

Overall Claim Findings by State

Findings chart

Denial Code Breakdown:

Findings chart

Reason for Denial

5D164 – No Documentation of Medical Necessity

  • Documentation submitted for review does not support the medical necessity of some of the services billed

How to Prevent Denials:

Documentation to Include:

  • ADL impairment
  • Documentation to support subsequent injections
  • Documentation of conservative pain treatments attempted and response to treatment prior to decision to utilize steroid injections
    • documentation to support the patient failed four weeks of non-surgical, non-injection care or an exception to the four week wait per L34807
  • Preoperative H&P
  • Imaging Requirements- preoperative lumbar imaging/radiology reports

5PE12 Round 1 Cardiac Rehabilitation with continuous ECG Monitoring (HCPCS 93798)

  Kentucky Ohio
Probes Completed 0 1
Providers Compliant after Round 1 Completion 0 1
Providers Non-compliant after Round 1 Completion 0 0
Providers with Non-responses to ADR's for Round 1 0 1

Overall Claim Findings by State

Findings chart

Denial Code Breakdown:

Findings chart

Reason for Denial

56900 – Requested Records Not Submitted

  • Medical records were not received in response to an ADR in the required time frame; therefore, unable to determine medical necessity and the claim was denied in the system

5C199 – Billing Error

  • The services billed were not covered. According to documentation in the medical record, the hospital has billed items and/or services in error

5H902 – Documentation did not Include Required Components

  • One or more of the following required components of the cardiac rehabilitation program were not found in the submitted documentation:
    • Physician-prescribed exercise
    • Cardiac Risk Factor Modification (education or training)
    • Psychosocial assessment
    • utcomes assessment
    • Individualized treatment plan

5PE22 Round 2 Cardiac Rehabilitation with continuous ECG Monitoring (HCPCS 93798)

  Kentucky Ohio
Probes Completed 0 1
Providers Compliant after Round 2 Completion 0 1
Providers Non-compliant after Round 2 Completion 0 0
Providers with Non-responses to ADR's for Round 2 0 1

Overall Claim Findings by State

Findings chart

Denial Code Breakdown:

Findings chart

Reason for Denial

56900 – Requested Records Not Submitted

  • Medical records were not received in response to an ADR in the required time frame; therefore, unable to determine medical necessity and the claim was denied in the system

How to Prevent Denials:

Documentation to Include:

  • Individualized Treatment Planned (ITP) established, reviewed, signed and dated by physician every 30 days to cover the DOS billed
  • All Cardiac Rehab (CR)/Intensive Cardiac Rehab (ICR) Program Component Requirements
    • Physician-prescribed exercise
    • Cardiac Risk Factor Modification (education or training tailored to meet the beneficiary needs)
    • Psychosocial assessment
    • Outcomes assessment (to determine the result of the interventions)
    • ITP
    • *These 5 components must be signed and dated by the physician every 30 days. Claims must have all 5 components in order to be paid. Components may be separate, or compiled together in the ITP*
  • Sessions for each DOS billed inclusive of minutes and an ECG monitoring strip
  • Physician prescribed exercise plan inclusive of:

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

  Kentucky Ohio
Probes Completed 2 9
Providers Compliant after Round 1 Completion 2 7
Providers Non-compliant after Round 1 Completion 0 2
Providers with Non-responses to ADR's for Round 1 0 3

Overall Claim Findings by State

Findings chart

Denial Code Breakdown:

Findings chart

Reason for Denial

56900 – Requested Records Not Submitted

  • Medical records were not received in response to an ADR in the required time frame; therefore, unable to determine medical necessity and the claim was denied in the system

5D501 – Billed in Error

  • The provider billed the claim in error

5D504 – Information Provided Does Not Support the Medical Necessity for This Service

  • Documentation provided does not support the medical necessity for the services

5D505 – Certification not valid

  • The certification or recertification for SNF admission was either not submitted for review or did not meet requirements for certification

5D507 – SNF MDS is not in the National Repository

  • The SNF MDS is not in the National Repository

5DOWN – Medical Review Downcode

  • The services billed were paid at a lower payment level. Based on medical review, the documentation submitted for review did not meet the criteria for the RUG code(s) billed. As a result, reimbursement has been adjusted to a lower payment level

5UPR1 Round 1 Review of SNF RUG Codes RUA, RUB, RUC, RUL, RUX, RVA, RVB, RVC, RVL and RVX

  Kentucky Ohio
Probes Completed 3 0
Providers Compliant after Round 1 Completion 3 0
Providers Non-compliant after Round 1 Completion 0 0
Providers with Non-responses to ADR's for Round 1 0 0

Overall Claim Findings by State

Findings chart

Denial Code Breakdown:

Findings chart

Reason for Denial

5D504 – Information Provided Does Not Support the Medical Necessity for This Service

  • Documentation provided does not support the medical necessity for the services

5DOWN – Medical Review Downcode

  • The services billed were paid at a lower payment level. Based on medical review, the documentation submitted for review did not meet the criteria for the RUG code(s) billed. As a result, reimbursement has been adjusted to a lower payment level

How to Prevent Denials:

Documentation to Include:

  • A clear picture of the beneficiary s medical condition that supports the data on the MDS and the RUG code(s) billed
  • 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

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

  Kentucky Ohio
Probes Completed 0 1
Providers Compliant after Round 1 Completion 0 1
Providers Non-compliant after Round 1 Completion 0 0
Providers with Non-responses to ADR's for Round 1 0 0

Overall Claim Findings by State

Findings chart

Denial Code Breakdown:

Findings chart

Reason for Denial

5D051 – Inpatient Rehabilitation Facility Interdisciplinary Team Conference Attendance

  • The submitted documentation did not support that all required participants of the IRF Interdisciplinary Team Conference (ITC) were present for each ITC throughout the IRF stay

5D067 – Inpatient Rehabilitation Facility Intensive Therapy Documentation

  • The submitted documentation did not support that the patient received intensive rehabilitation therapy services

How to Prevent Denials:

Documentation to Include:

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

  Kentucky Ohio
Probes Completed 1 3
Providers Compliant after Round 1 Completion 1 3
Providers Non-compliant after Round 1 Completion 0 0
Providers with Non-responses to ADR's for Round 1 0 2

Overall Claim Findings by State

Findings chart

Denial Code Breakdown:

Findings chart

Reason for Denial

56900 – Requested Records Not Submitted

  • Medical records were not received in response to an ADR in the required time frame; therefore, unable to determine medical necessity and the claim was denied in the system

5D402 – Days/Units of Service Does Not Meet the Required Minimum or Exceeds the Acceptable Maximum

  • The number of days or units of service billed does not meet the required minimum OR exceeds the acceptable maximum for sessions one (1) through thirty-six (36)
  • The claim was billed without the KX modifier for sessions over thirty-six (36)
  • Documentation was not submitted to support medical necessity for additional session(s)

5D901/5H901 – Pulmonary Rehab Not Warranted for Diagnosis

  • The claim was fully or partially denied as the condition required for coverage of pulmonary rehabilitation services was not submitted in the medical record
  • Medicare coverage of pulmonary rehabilitation services is defined in the Code of Federal Regulations (42 CFR 410.47). Coverage for pulmonary rehabilitation items and services is limited to patients with moderate to very severe COPD (defined as GOLD classification II, III, and IV), when referred by the physician treating the chronic respiratory disease

5D902/5H902 – Documentation did not Include Required Components

  • The claim was fully or partially denied because the following components of the pulmonary rehabilitation program were not found in the submitted documentation:
    • Physician-prescribed exercise
    • Respiratory Risk Factor Modification (education or training)
    • Psychosocial assessment
    • Outcomes assessment
    • Individualized treatment plan

How to Prevent Denials:

Documentation to Include:

  • Individualized Treatment Planned (ITP) established, reviewed, signed and dated by physician every 30 days to cover the DOS billed
  • All Pulmonary Rehabilitation Program Component Requirements
    • oPhysician-prescribed exercise
    • oPulmonary risk factor modification (education or training tailored to meet the beneficiary needs)
    • oPsychosocial assessment
    • oOutcomes assessment (to determine the result of the interventions)
    • oITP
  • Clear documentation of total session minutes provided for DOS billed
  • Physician prescribed exercise (some aerobic exercise must be included in each session) will include:
    • oMode of exercise (typically aerobic)
    • oTarget intensity (e.g., a specified percentage of the maximum predicted heart rate, or number of METs)
    • oDuration of each session (e.g., "20 minutes")
    • oFrequency (number of sessions per week)
  • Diagnostic criteria of the Pulmonary Function Test (PFT) regarding FEV1/FVC < 70% and FEV1<80% for moderate to very severe COPD (defined as GOLD classification II, III and IV)

    *These 5 components must be signed and dated by the physician every 30 days. Claims must have all 5 components in order to be paid. Components may be separate, or compiled together in the ITP*

    *Medicare covers pulmonary rehabilitation items and services for patients with moderate to very severe COPD (defined as GOLD classification II, III, and IV), when referred by the physician treating the chronic respiratory disease*

    MCR Claims Processing Manual, Chapter 32 Pulmonary Rehab section 140.4External PDF


    MCR Benefit Policy Manual Chapter 15 Pulmonary RehabExternal PDF

    42 CFR 410.47 – Pulmonary rehabilitation program: Conditions for coverageExternal Website

    Pulmonary Rehabilitation Coverage and Documentation Requirements Article

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

  Kentucky Ohio
Probes Completed 0 1
Providers Compliant after Round 1 Completion 0 1
Providers Non-compliant after Round 1 Completion 0 0
Providers with Non-responses to ADR's for Round 1 0 0

Overall Claim Findings by State

Findings chart

Denial Code Breakdown:

Findings chart

Reason for Denial

5J504 – Need for Services/Item Not Medically And Reasonable Necessary (For claims after 10/1/13)

  • The documentation submitted for review did not support the medical necessity of the services provided

How to Prevent Denials:

Documentation to Include:

5PE25 Round 2 Review of Inpatient Claims for DRG 470 Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity without MCC

  Kentucky Ohio
Probes Completed 0 1
Providers Compliant after Round 1 Completion 0 1
Providers Non-compliant after Round 1 Completion 0 0
Providers with Non-responses to ADR's for Round 1 0 0

Overall Claim Findings by State

Findings chart

Denial Code Breakdown:

Findings chart

Reason for Denial

5J504 – Need for Services/Item Not Medically And Reasonable Necessary (For claims after 10/1/13)

  • The documentation submitted for review did not support the medical necessity of the services provided

How to Prevent Denials:

Documentation to Include:

  • Documentation of conservative pain treatments attempted with response to treatment
  • ADL impairment
  • H&P
  • Pre-operative radiographic imaging
  • Operative report
  • All services were medically necessary on an inpatient basis instead of a less intensive setting
  • All clinical information for the dates of service billed
    • o physician progress notes, physical examinations, assessments, diagnostic tests and laboratory results, history and physical, nurse s notes, consultations, surgical procedures, orders and discharge summary, and any other documentation to support the inpatient admission
  • Necessity of the procedure, including pre-surgical interventions and outcomes

    CGS Major Joint Article with link to MLN Matters

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. Avoid 56900 denials by ensuring all the required documentation is submitted for review, the information is accurate and that the claim was billed timely (within 45 days) in response to an Additional Documentation Request (ADR).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.

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

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