May 16, 2019 Updated: December 10, 2019
Targeted Probe and Educate Progress Update
The Centers for Medicare & Medicaid Services (CMS) Change Request 10249
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-Responses 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-Responses 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.
Top Denial Reasons January 1, 2019 – March 31, 2019
- Face-to-Face missing/incomplete/untimely
- Initial certification invalid
- Therapy visits not medically necessary
- Recert estimate missing/invalid
- 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 Certification
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).
- FTF Documentation Denials accounted for approximately 30% of the total Targeted Probe and Educate denials.
Top 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-Responses 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-Responses 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.
Top Denial Reasons January 1, 2019 – March 31, 2019
- Terminal prognosis not supported
- Physician Narrative missing/invalid
- Notice of Election is invalid
- Terminal prognosis not supported accounted for approximately 47% of the total Targeted Probe and Educate denials.
Refer to the CGS Hospice Denial Fact Sheet—Six-Month Terminal Prognosis Not Supported Web page for documentation tips and access to the Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 9). - Physician narrative missing/invalid accounted for approximately 17% of the total Targeted Probe and Educate denials.
Refer to the CGS Hospice Denial Fact Sheet – Missing/Incomplete/Untimely Certification/Recertification Web page for documentation tips and access to the Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 9) and SE1628 Documentation Requirements for the Hospice Physician Certification/Recertification. - Notice of Election is invalid accounted for approximately 11% of the total Targeted Probe and Educate denials.
Refer to the CGS Hospice Denial Fact Sheet – Missing/Incomplete/Untimely Election Statement and Hospice Election Requirements Web pages for documentation tips and access to the Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 9).
- Terminal prognosis not supported accounted for approximately 47% of the total Targeted Probe and Educate denials.
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) offered through our web portal.
References
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