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TPE Results

TPE Update: July – September 2025

Based on data analysis, Medical Review initiated complex review edits for specific providers that demonstrated a high risk for improper payment. CGS offered education to providers during, and upon completion of, each round of review.

The information below describes the Targeted Probe and Educate (TPE) results for home health and hospice (HHH) providers from July – September 2025.


Home Health Probes Completed

Current Edits

The primary focus of these reviews is to determine if the medical record documentation supports Medicare guidelines for medical necessity of the services billed. Current home health edits for TPE include:

Review Topic Edit Numbers Description Review Type
Medical necessity 5A007
5B007
5C007
This edit selects providers who submitted home health claims with 2 to 6 visits and diagnosis code I11.0, Z46.6, J44.0, J44.1, J44.81, J44.89, J44.9, (J44, J44.8 discontinued 10.01.2023), I10, G20.A1, G20.A2, G20.B1, G20.B2, G20.C, (G20 discontinued 10.01.2023), I25.10, N39.0, J18.9, or I87.2. TPE prepayment review
New providers 5A006
5B006
5C006
This edit selects home health claims for relatively new providers who have submitted at least 50 claims. TPE prepayment review
Medical necessity 5N000
5T000
5V000
This edit selects providers who submitted home health claims with 2 to 6 visits and diagnosis code I11.0, Z46.6, J44.0, J44.1, J44.81, J44.89, J44.9, (J44, J44.8 discontinued 10.01.2023), I10, G20.A1, G20.A2, G20.B1, G20.B2, G20.C, (G20 discontinued 10.01.2023), I25.10, N39.0, J18.9, or I87.2. TPE
Round 1 postpayment
Round 2 prepayment
Round 3 prepayment

Results

Results 5A007
Round 1
5B007
Round 2
5C007
Round 3
5A006
Round 1
5B006
Round 2
5V000
Round 3
Probes completed 1 12 5 12 1 1
Providers compliant after round completion 1 10 4 9 1 1
Providers non-compliant after round completion (advancing) 0 2 1 3 0 0
Providers with non-response to ADRs 0 2 0 0 1 0
Education contacts 0 38 13 27 1 8

Findings by State

Summary of review findings for providers that completed rounds of review (by state):

Summary of review findings

Summary of review findings

Summary of review findings

Top Denial Reasons

See Home Health Medical Review Denials for details and resources to help avoid future claim denials.

Rank Reason Code Description % of TPE Denials
1 5HC01 Face-to-face documentation missing, incomplete, or untimely 25.8%
1 5HN18 Skilled nursing not medically necessary 21.6%
2 5HC09 Initial certification invalid 20.6%
3 5HC04 Plan of care/certification not signed 9.8%
4 5HY01 Therapy visits not medically necessary 6.7%

Hospice Probes Completed

Current Edits

The primary focus of these reviews is to determine if medical record documentation supports the Medicare guidelines for medical necessity of the services billed. Current hospice edits for TPE include:

Review Topic Edit Numbers Description Review Type
LOS with non-oncologic diagnosis 5D000
5E000
5F000
This edit selects hospice providers who submitted claims with length of stay (LOS) >730 days and non-oncologic diagnosis code. TPE prepayment review
GIP LOC 5D006
5E006
5F006
This edit selects hospice providers who submitted claims with revenue code 0656 greater than or equal to 7 days. TPE prepayment review
New providers 5D008
5E008
5F008
This edit selects hospice claims for relatively new providers who have submitted at least 50 claims. TPE prepayment review
LOS 313-515 days 5D010
5E010
5F010
This edit selects hospice providers who submitted claims with length of stay (LOS) 313-515 days. TPE prepayment review

Results

Results 5E000
Round 2
5D008
Round 1
5E008
Round 2
5F008
Round 3
5D010
Round 1
5E010
Round 2
5F010
Round 3
Probes completed 2 16 1 10 6 11 1
Providers compliant after round completion 1 10 1 6 0 2 0
Providers non-compliant after round completion (advancing) 1 6 0 4 6 9 1
Providers with non-responses to ADRs 0 2 0 0 2 1 0
Education contacts 7 40 3 62 30 78 1

Findings by State

Summary of review findings for providers that completed rounds or review (by state):

Summary of review findings

Summary of review findings

Summary of review findings

Top Denial Reasons

See Hospice Medical Review Denials for details and resources to help avoid future claim denials.

Rank Reason Code Description % of TPE Denials
1 5PM01 Terminal prognosis not supported 57.4%
2 5PX06 Notice of Election (NOE) invalid 31.2%
3 5PC08 Face-to-face encounter invalid 2.4%
4 5PC01 Physician narrative missing or invalid 2.2%
5 56900 Non-receipt of medical records 1.4%

Education

CGS offers providers with a moderate to high error rate an individualized education session in which each claim found in error is discussed and any questions answered. These education sessions may occur via webinar, web-based presentation, or traditional teleconference. Other methods may also be available. Providers may also submit questions or request education via email: J15HHPROBEANDEDUCATION@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 our Medical Review Activity Log, and use tools such as Comparative Billing Reports (CBRs) available in the myCGS portal.

References

Updated: 11.20.2025

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