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September 5, 2018 - Revised: 01.18.19

J15 Targeted Probe and Educate Status Update

April 1, 2018- June 30, 2018

Medical Review initiated the Targeted Probe and Educate (TPE) process on October 1, 2017 per CR10249. TPE probe edits were initiated for specific providers identified through data analysis demonstrating high risk for improper payment and previous probe and targeted reviews. Education has been offered to providers throughout, and upon completion of, Round 1 and initiation of Round 2 of the Targeted Probe and Educate process.  Medical Review initiated 61 provider edits during the period of April 1, 2018 through June 30, 2018. Twenty-six providers progressed to Round 2 based on previous probe or targeted review results. The chart below lists numbers of completed probes between October 1, 2017-June 30, 2018.

Results

Kentucky

Ohio

Probes Completed

9

6

Providers Compliant after Round 1 Completion

2

1

Providers Non-compliant after Round 1 Completion

7

5

Providers with Non-Reponses to ADR’s for Round 1

2

1

This chart reflects probes completed between April 1, 2018 –June 30, 2018

Results

Kentucky

Ohio

Probes Completed

6

6

Providers Compliant after Round 1 Completion

1

1

Providers Non-compliant after Round 1 Completion

5

5

Providers with Non-Reponses to ADR’s for Round 1

1

1

The results of the probes per strategy item are listed below:

Strategy: Ambulance- Round 1 

Results

Kentucky

Ohio

Probes Completed

0

2

Providers Compliant after Round 1 Completion

0

0

Providers Non-compliant after Round 1 Completion

0

2

Providers with Non-Reponses to ADR’s for Round 1

0

0

Ambulance - Round 1

Findings:

  • Documentation did not support that beneficiary could not be transported by any other means.
  • Conditions listed on Provider Certification Statement (PCS) regarding medical necessity for the service were not reflected in the documentation by ambulance personnel.

Strategy: Critical Care – Round 1

Results

Kentucky

Ohio

Probes Completed

0

1

Providers Compliant after Round 1 Completion

0

0

Providers Non-compliant after Round 1 Completion

0

1

Providers with Non-Reponses to ADR’s for Round 1

0

0

Critical Care - Round 1

Findings:

  • Documentation did not support medical necessity of the service with evidence of imminent threat of high complexity decision making.
  • Documentation did not meet required Evaluation and Management guidelines for the level of service billed.

Strategy: Emergency Room Visits

Results

Kentucky

Ohio

Probes Completed

1

0

Providers Compliant after Round 1 Completion

0

0

Providers Non-compliant after Round 1 Completion

1

0

Providers with Non-Reponses to ADR’s for Round 1

0

0

Emergency Room - Round 1

Findings:

  • Documentation did not support a significant face to face visit occurred
  • Did not meet split shared guidelines
  • Medical necessity issues – Billed higher level than documented or was reasonable for the service rendered
  • Lack of high level decision making

Strategy: Hospital Visits- Round 1

Results

Kentucky

Ohio

Probes Completed

1

1

Providers Compliant after Round 1 Completion

0

1

Providers Non-compliant after Round 1 Completion

1

0

Providers with Non-Reponses to ADR’s for Round 1

1

0

Hospital Visits - Round 1

Findings:

  • Not meeting the key components required for billing CPT 99233, specifically lack of detailed history and medical decision making of high complexity.
  • Failure to provide required documentation as requested
  • Visit billed by wrong provider
  • Split/Shared visit billed with no documentation of significant face-to-face by provider

Strategy: Labs-Round 1

Results

Kentucky

Ohio

Probes Completed

0

1

Providers Compliant after Round 1 Completion

0

0

Providers Non-compliant after Round 1 Completion

0

1

Providers with Non-Reponses to ADR’s for Round 1

0

0

Labs - Round 1

Findings:

  • Lack of documentation to support clinical patient history of DSM-V criteria per LCD L35443.
  • Order not obtained on date of testing per IOM 100-8, Chapter 3, Section 3.3.2.4.

Strategy: Prolonged Physician Services-Code 99356- Round 1

Results

Kentucky

Ohio

Probes Completed

1

0

Providers Compliant after Round 1 Completion

0

0

Providers Non-compliant after Round 1 Completion

1

0

Providers with Non-Reponses to ADR’s for Round 1

0

0

Code 99356 - Round 1

Findings:

  • Documentation did not contain enough information to substantiate the medical necessity of the prolonged service. Without an exacerbation of chronic condition, acute issues, or change in treatment at the time of the encounter, stable, chronic condition services are not considered medically necessary.
  • Frequency and duration of prolonged services was not documented to support medical necessity.

Strategy: Nursing Facility Visits- Round 1

Results

Kentucky

Ohio

Probes Completed

0

1

Providers Compliant after Round 1 Completion

0

0

Providers Non-compliant after Round 1 Completion

0

1

Providers with Non-Reponses to ADR’s for Round 1

0

1

Nursing Facility Visits - Round 1

Findings:

  • Handwriting illegible or scribed information not signed by scribe and no attestation provided.
  • Documentation did not support that a face-to-face examination occurred between the provider and the patient.
  • Provided plans of care illegible or dated months prior to visits without updates.
  • Documentation did not support required elements of code billed.

Strategy: Office Visits – Round 1

esults

Kentucky

Ohio

Probes Completed

2

0

Providers Compliant after Round 1 Completion

1

0

Providers Non-compliant after Round 1 Completion

1

0

Providers with Non-Reponses to ADR’s for Round 1

0

0

Office Visits - Round 1

Findings:

  • Stable, chronic pain management without new problems or exacerbation of problems.
  • Stable, low-risk patients being seen monthly for refill of narcotics.

Strategy: Office Visits – Round 2

Results

Kentucky

Ohio

Probes Completed

1

0

Providers Compliant after Round 2 Completion

0

0

Providers Non-compliant after Round 2 Completion

1

0

Providers with Non-Reponses to ADR’s for Round 2

0

0

Office Visits - Round 2

Findings:

  • Documentation did not support medical necessity of visits every two weeks for stable, low-risk patients

How to Prevent Denials:

Next Steps:

Providers found to be non-compliant at the completion of Round 1 will advance to Round 2 and those found to be non-compliant at the completion of Round 2 will advance to Round 3 of TPE at least 45 days after completion of the post probe educational session.  All providers under TPE review will be offered education at the end of each round.  Providers do not have to be identified for TPE to request education. Part B Providers may submit TPE questions or request education via the Part B TPE email box (Please include your Provider Number in the subject of the email):

J15BprobeandEducation@cgsadmin.com

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

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

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