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May 16, 2019

Targeted Probe and Educate Progress Update

The Centers for Medicare & Medicaid Services (CMS) Change Request 10249External PDF implemented the Targeted Probe & Educate (TPE) process, effective October 1, 2017. The following provides progress of TPE from January 1, 2019 – March 31, 2019.

Findings

Medical Review initiated complex review edits for specific providers identified through data analysis demonstrating high risk for improper payment. Education has been offered to providers throughout and upon completion of each Round of TPE review. Current TPE Home Health and Hospice Results are as follows:

Home Health

Probes completed January 1, 2019 – March 31, 2019

Eligibility and Medical Necessity edit 5A000

Results Home Health
Probes Completed 81
Providers Compliant after Round 1 Completion 2
Providers Non-compliant after Round 1 Completion (advancing to Round 2) 79
Providers with Non-Reponses to ADR's for Round 1 19

Eligibility and Medical Necessity edit 5B000 (Round 2)

Results Home Health
Probes Completed 10
Providers Compliant after Round 2 Completion 2
Providers Non-compliant after Round 2 Completion (advancing to Round 3) 8
Providers with Non-Reponses to ADR's for Round 2 1

Findings by State

CGS is providing an overview of review findings by state for providers who have completed Round 1 and Round 2.

Decisions by State

Decisions by State

Top Denial Reasons January 1, 2019 – March 31, 2019

  1. Face-to-Face missing/incomplete/untimely
  2. Initial certification invalid
  3. Therapy visits not medically necessary
  4. Recert estimate missing/invalid
  5. The order(s) are incomplete

    • FTF Documentation Denials accounted for approximately 30% of the total Targeted Probe and Educate denials.
      • Actual FTF encounter document not submitted
      • Certifying physician did not document the date of the FTF encounter
      • CGS Home Health Physician Certification Web page
      • Community physician was not identified when a physician who would not be following the patient after discharge signed the certification
      • Required elements for initial certification (initial plan of care, initial certification, initial encounter documentation) were not submitted for recertification

      Refer to the CGS Home Health Coverage Guidelines Web page for a variety of resources on the home health FTF encounter.

    • Initial certification invalid accounted for approximately 14% of the total Targeted Probe and Educate denials.

      Refer to the CGS Home Health Physician Certification Web page for documentation tips and access to the Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 7).

    • Documentation did not support medical necessity of therapy services accounted for approximately 7% of the total Targeted Probe and Educate denials.

      Refer to the CGS Physical Therapy Web page for documentation tips, access to the Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 7) therapy information and the Local Coverage Determination for physical therapy services.

    • Recertification estimate missing/invalid accounted for approximately 6% of the total Targeted Probe and Educate denials.

      Dates of Service before January 1, 2019. The physician's estimate of how much longer skilled services will be required

      • Is the physician's estimate stated in a measurable unit of time (i.e. days, weeks, months, years)?

      Refer to the CGS Home Health Physician Recertification Estimate Tip Web page for documentation tips, access to the Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 7).

    • The order(s) are incomplete accounted for approximately 6% of the total Targeted Probe and Educate denials.

      Refer to the CGS Physician Orders, Plan of Care and Certification and Home Health Denial Fact Sheet – Missing/Incomplete/Untimely Plan of Care or CertificationPDF Web pages for documentation tips and access to the Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 7 Specificity of Orders §30.2.2 and Verbal Orders §30.2.5).

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Hospice

Probes completed January 1, 2019 – March 31, 2019

LOS with Non-Oncologic Diagnosis edit 5D000

Results Hospice
Probes Completed 7
Providers Compliant after Round 1 Completion 1
Providers Non-compliant after Round 1 Completion (advancing to Round 2) 6
Providers with Non-Reponses to ADR's for Round 1 1

GIP LOC edit 5D006

Results Hospice
Probes Completed 4
Providers Compliant after Round 1 Completion 2
Providers Non-compliant after Round 1 Completion (advancing to Round 2) 2
Providers with Non-Reponses to ADR's for Round 1 0

Findings by State

CGS is providing an overview of review findings by state for providers who have completed Round 1.

Decisions by State

Top Denial Reasons January 1, 2019 – March 31, 2019

  1. Terminal prognosis not supported
  2. Physician Narrative missing/invalid
  3. Notice of Election is invalid

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Education

Providers with a moderate to high error rate will be offered an individualized education session where each claim found in error will be discussed and any questions will be answered. CGS offers education sessions via webinar, web-based presentation, or traditional teleconferences. Other methods may also be available. Providers may also submit questions or request education via the home health and hospice TPE email box at J15HHPROBEANDEDUCATION@CGSADMIN.COM.

Next Steps

Providers found to be non-compliant at the completion of Round 1/2 will advance to Round 2/3 of TPE at least 45 days from completion of the 1:1 post probe education call date. CGS offers education at any time for providers. Providers do not have to be identified for TPE to request education. CGS encourages providers to request education and conduct self-monitoring based on our posted Medical Review Activity Log and using tools such as Comparative Billing Reports (CBRs)PDF offered through our web portal.

References

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