May 25, 2023
Targeted Probe and Educate Program to Focus on Laboratory Testing
The CGS Targeted Probe and Educate (TPE) program will begin a review of claims associated with laboratory testing. Coverage guidance is available in the Local Coverage Determination (LCD) policies L36029 and L33996
.
Laboratory Testing claims must meet all medically reasonable and necessary requirements outlined in the applicable statute, regulations and manual provisions.
We expect the documentation you submit to include a copy of the following information from each patient’s medical record that is legible and signed:
- Beneficiary’s name
- Date of service
- Signed medical records that establish:
- Medical necessity and relevant history
- Signed order or intent to order noted in office record
- Ordering provider’s assessment of the patient as it relates to the patient’s complaint at that visit including patient history, physical examination, and previous laboratory findings
- Results of pertinent tests/procedures
- Additionally, for Urine Drug Testing:
- Current treatment plan
- Prescribed medication(s)
- Risk assessment
- Copy of any mandatory ABNs
- Appropriate signatures
- Signature and credentials of person performing the service must meet CMS requirements
- Amendments/corrections/delayed entries are properly identified
For additional documentation requirements, please reference:
- CMS IOM Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15
- CMS IOM Pub. 100-04, Medicare Claims Processing Manual, Chapter 16
CPT codes under review will include:
- G0481 – Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers)
- G0483 – Drug test(s) definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers)
- 82306 – Vitamin D, 25 hydroxy
For more information on the TPE program, please reference:
- CGS Targeted Probe and Educate (TPE) webpage
- CGS Targeted Probe and Educate (TPE) Process webpage
- Targeted Probe and Educate: Did You Know?
- CMS) Targeted Probe and Educate webpage
We encourage you to use the myCGS Portal to identify claims selected for review and submit your documentation. For more information, including step-by-step instructions, please reference the myCGS User Manual.