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TPE Results

April - June 2026

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 Targeted Probe and Educate (TPE) results for home health and hospice providers.

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 TPE edits for home health providers include:

Review Topic Edit Numbers Description Review Type
Medical necessity 5A007
5B007
5C007
5G007
Claims with 2-6 visits and diagnosis code I11.0, Z46.6, J44.0, J44.1, J44.81, J44.89, J44.9, I10, G20.A1, G20.A2, G20.B1, G20.B2, G20.C, I25.10, N39.0, J18.9, or I87.2 TPE prepayment review
New providers 5A006
5B006
5C006
5G006
Claims for new providers with at least 50 claim submissions TPE prepayment review
Medical necessity 5N000
5T000
5V000
5G000
Claims with 2-6 visits and diagnosis code I11.0, Z46.6, J44.0, J44.1, J44.81, J44.89, J44.9, I10, G20.A1, G20.A2, G20.B1, G20.B2, G20.C, I25.10, N39.0, J18.9, or I87.2. TPE
Round 1 postpayment
Round 2 prepayment
Round 3 prepayment Round 4 prepayment

Results

Results 5A006
Round 1
5B006
Round 2
5C006
Round 3
5A007
Round 1
5B007
Round 2
5C007
Round 3
5V000
Round 3
Probes completed 8 1 1 21 11 6 1
Providers compliant after round completion 4 0 0 9 7 5 1
Providers non-compliant after round completion (advancing) 4 1 1 12 4 1 0
Providers with non-response to ADRs 1 0 0 3 0 0 0
Education contacts 14 1 0 25 26 6 3

Findings by State

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

Summary of findings for providers that completed rounds of review

Summary of findings for providers that completed rounds of review

Summary of findings for providers that completed rounds of review

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 5HN18 Skilled nursing not medically necessary 32.2%
2 5HC09 Initial certification invalid 17.1%
3 5HY01 Therapy visits not medically necessary 14.7%
4 5HC01 Face-to-face documentation is missing, incomplete, or untimely 13.7%
5 5HC05 No Plan of Care/certification 5.2%

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 TPE edits for hospice providers include:

Review Topic Edit Numbers Description Review Type
LOS with non-oncologic diagnosis 5D000
5E000
5F000
5J000
Claims with length of stay (LOS) >730 days and non-oncologic diagnosis code TPE prepayment review
GIP LOC 5D006
5E006
5F006
5J006
Claims with revenue code 0656 (7 days or more) TPE prepayment review
New providers 5D008
5E008
5F008
5J008
Claims for new providers with at least 50 claim submissions TPE prepayment review
LOS 313-515 days 5D010
5E010
5F010
5J010
Claims with length of stay (LOS) 313-515 days TPE prepayment review

Results

Results 5D000
Round 1
5E000
Round 2
5D008
Round 1
5E008
Round 2
5F008
Round 3
5D010
Round 1
5E010
Round 2
5F010
Round 3
5F006 Round 3
Probes completed 2 3 14 2 5 11 6 6 1
Providers compliant after round completion 0 1 7 1 2 2 4 3 1
Providers non-compliant after round completion (advancing) 2 2 7 1 3 9 2 3 0
Providers with non-response to ADRs 1 0 1 1 0 1 0 0 0
Education contacts 0 0 27 12 3 17 21 3 4

Findings by State

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

Summary of findings for providers that completed rounds or review

Summary of findings for providers that completed rounds or review

Summary of findings for providers that completed rounds or review

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 53.6%
2 5PX06 Notice of Election (NOE) invalid 26.4%
3 56900 Medical records not received 2.9%
4 5PC01 Physician certification of terminal illness missing or invalid 2.9%
5 5PX07 NOE not present 2.6%

Education

Education sessions are available via webinar, teleconference, or other methods:

CGS offers an individualized education session to providers with a moderate to high error rate. This includes the opportunity to discuss each claim found in error and address any questions or concerns.

Any provider may also request an individualized education session at any time.

Widespread education sessions are posted on the Calendar of Events.

Please email questions or education requests to: J15HHPROBEANDEDUCATION@CGSADMIN.COM.

Next Steps

At the completion of TPE round 1/2, providers identified as non-compliant 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 elected 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: 09.01.2026

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