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):



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):



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
- Targeted Probe and Educate (TPE)

- Educational Materials & Resources
- Medical Review Additional Development Request (ADR) Process: Prepayment Review
Updated: 11.20.2025

