TPE Results
TPE Update: January – November 2025
Based on data analysis, Medical Review initiated complex review edits for specific providers that demonstrated a high risk for improper payment. CGS offered targeted education to providers during, and upon completion of, each round of review. Widespread education included website articles and webinars conducted with Provider Outreach & Education.
The information below describes Targeted Probe and Educate (TPE) results for Part B providers from January – November 2025.
Probes Completed
| Drugs & Biologicals | ||
|---|---|---|
| Results | Kentucky | Ohio |
| Probes completed | 6 | 6 |
| Providers compliant after round 1 completion | 5 | 5 |
| Providers referred to CMS after round 3 completion | 1 | 1 |
| Providers with non-response to ADRs | 2 | 1 |
Top Findings
- The documentation submitted lacked elements such as purchase orders and progress notes that support medical necessity for the drug or biological administration.
- Failure to provide supporting documentation for a dosage above FDA guidelines.
- Incorrect modifier usage.
| Outpatient Physical & Occupational Therapy Services | ||
|---|---|---|
| Results | Kentucky | Ohio |
| Probes completed | 5 | 5 |
| Providers compliant after round 1 completion | 1 | 0 |
| Providers compliant after round 3 completion | 2 | 1 |
| Providers referred to CMS after round 3 completion | 1 | 1 |
| Providers with non-response to ADRs for Round 1 | 1 | 2 |
Top Findings
- Missing documentation such as physician order, signed certification, progress notes.
- Documentation didn’t support medical necessity for visits exceeding the recommended amount.
- Incorrect modifier usage.
| Outpatient Physical & Occupational Therapy Services with Modifier KX | ||
|---|---|---|
| Results | Kentucky | Ohio |
| Probes completed | 8 | 17 |
| Providers compliant after round 1 completion | 2 | 4 |
| Providers compliant after round 2 completion | 2 | 7 |
| Providers compliant after round 3 completion | 1 | 2 |
| Providers referred to CMS after round 3 completion | 0 | 0 |
| Providers with non-response to ADRs | 2 | 4 |
Top Findings
- Missing documentation such as physician order, signed certification, progress notes.
- Documentation didn’t support medical necessity for visits exceeding the recommended amount.
- Incorrect modifier usage.
| Annual Wellness Visit Services | ||
|---|---|---|
| Results | Kentucky | Ohio |
| Probes completed | 1 | 2 |
| Providers compliant after round 2 completion | 1 | 1 |
| Providers with non-response to ADRs for round 1 | 1 | 1 |
Top Findings
- Documentation didn’t support medical necessity due to missing functional ability, safety assessment, or cognitive assessment.
- Non-response to ADRs
- The performing provider isn’t the billing provider.
| Ophthalmic Services (66984, 66989 & 67113) | ||
|---|---|---|
| Results | Kentucky | Ohio |
| Probes completed | 3 | 5 |
| Providers compliant after round 1 completion | 3 | 2 |
| Providers compliant after round 3 completion | 0 | 2 |
| Providers referred to CMS after round 3 completion | 0 | 1 |
| Providers with non-response to ADRs for round 1 | 0 | 2 |
Top Findings
- Missing documentation to support medical necessity, including visual acuity requirements.
- Non-response to ADRs.
| Diagnostic Imaging Services | ||
|---|---|---|
| Results | Kentucky | Ohio |
| Probes completed | 2 | 6 |
| Providers compliant after round 1 completion | 0 | 0 |
| Providers compliant after round 3 completion | 0 | 1 |
| Providers referred to CMS after round 3 completion | 1 | 1 |
| Providers with non-response to ADRs for round 1 | 2 | 3 |
Top Findings
- Missing documentation to support medical necessity, including orders or documentation to support the need for CT.
- Non-response to ADRs.
- Incorrect date of service.
| Evaluation & Management Services | ||
|---|---|---|
| Results | Kentucky | Ohio |
| Probes completed | 4 | 8 |
| Providers compliant after round 1 completion | 1 | 2 |
| Provider compliant after round 2 completion | 1 | 6 |
| Providers with non-response to ADRs for round 1 | 1 | 4 |
Top Findings
- Documentation didn’t support the level of service billed.
- Non-response to ADRs.
| Laboratory Services | ||
|---|---|---|
| Results | Kentucky | Ohio |
| Probes completed | 12 | 10 |
| Providers compliant after round 1 completion | 0 | 0 |
| Provider compliant after round 2 completion | 1 | 1 |
| Provider compliant after round 3 completion | 1 | 0 |
| Provider referred to CMS after round 3 completion | 3 | 4 |
| Providers with non-response to ADRs for round 1 | 5 | 7 |
Top Findings
- Documentation didn’t support testing frequency.
- Documentation missing elements such as lab results, order, or documentation to support medical necessity.
- Non-response to ADRs.
| Nail Debridement Services | ||
|---|---|---|
| Results | Kentucky | Ohio |
| Probes completed | 4 | 13 |
| Providers compliant after round 1 completion | 1 | 4 |
| Provider compliant after round 2 completion | 1 | 0 |
| Provider compliant after round 3 completion | 1 | 1 |
| Provider referred to CMS after round 3 completion | 0 | 1 |
| Providers with non-response to ADRs for round 1 | 2 | 5 |
Top Findings
- Documentation didn’t support description of each nail requiring debridement.
- Documentation doesn’t support systemic disease or ambulation status.
- Non-response to ADRs.
| Psychiatry Services | ||
|---|---|---|
| Results | Kentucky | Ohio |
| Probes completed | 0 | 6 |
| Provider compliant after round 2 completion | 0 | 2 |
| Provider referred to CMS after round 3 completion | 0 | 1 |
| Providers with non-responses to ADRs for round 1 | 0 | 5 |
Top Findings
- Missing documentation elements necessary to support medical necessity.
- Non-response to ADRs.
| Spinal Pain Management Services | ||
|---|---|---|
| Results | Kentucky | Ohio |
| Probes completed | 3 | 5 |
| Provider compliant after round 2 completion | 0 | 2 |
| Provider compliant after round 3 completion | 0 | 1 |
| Provider referred to CMS after round 3 completion | 2 | 0 |
| Providers with non-response to ADRs for round 1 | 3 | 2 |
Top Findings
- Missing documentation to support medical necessity such as conservative measures, diagnostic imaging report, or notification to primary care provider of continuation of steroid use.
- Documentation doesn’t support medical necessity.
- Non-response to ADRs.
Education
Provider education offered via webinar or traditional teleconference includes:
- Individualized education sessions after each round of review.
- Intra-probe education sessions for providers with high curable errors.
- Widespread Level II webinars that provide TPE data, a high-level policy overview, and documentation examples.
Website articles published include:
- TPE & Appeals Processes
- Claim Resubmission/Rebilling
- Billing Instructions for Concurrent Care – E&M Service: Similar Services from Multiple Physicians & NPPs Within the Same Group
- Billing Professional & Technical Components
Please submit questions or education requests to J15BProbeandEducation@cgsadmin.com.
Next Steps
At the completion of TPE round 1/2, providers identified as non-compliant will advance to TPE round 2/3 at least 45 days from the 1:1 post-probe education call completion date. You may request education at any time even if you aren’t selected for TPE. CGS encourages providers to request education, conduct self-monitoring based on posted MR Activities, and use other self-service tools available on our website.
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