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October 31, 2019

Targeted Probe and Educate Progress Update

The Centers for Medicare & Medicaid Services (CMS) Change Request 10249Review decisions by state implemented the Targeted Probe & Educate (TPE) process, effective October 1, 2017. The following provides progress of TPE from October 1, 2017 – September 30, 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 October 1, 2017 – September 30, 2019

Eligibility and Medical Necessity edit
Results 5A000
Round 1
5B000
Round 2
5C000
Round 3
Probes Completed 388 158 1
Providers Compliant after Round Completion 51 66 0
Providers Non-compliant after Round Completion (advancing) 337 92 1
Providers with Non-Reponses to ADRs for Round 80 16 0

LOS >120 Days edit
Results 5A002
Round 1
5B002
Round 2
5C002
Round 3
Probes Completed 1 0 0
Providers Compliant after Round Completion 0 0 0
Providers Non-compliant after Round Completion (advancing) 1 0 0
Providers with Non-Reponses to ADRs for Round 0 0 0

LOS >180 Days edit
Results 5A003
Round 1
5B003
Round 2
5C003
Round 3
Probes Completed 1 0 0
Providers Compliant after Round Completion 0 0 0
Providers Non-compliant after Round Completion (advancing) 1 0 0
Providers with Non-Reponses to ADRs for Round 1 0 0

No response to ADR edit
Results 5A004
Round 1
5B004
Round 2
5C004
Round 3
Probes Completed 65 22 0
Providers Compliant after Round Completion 5 12 0
Providers Non-compliant after Round Completion (advancing) 60 10 0
Providers with Non-Reponses to ADRs for Round 30 2 0

Low Visit Utilization edit
Results 5A005
Round 1
5B005
Round 2
5C005
Round 3
Probes Completed 10 0 0
Providers Compliant after Round Completion 4 0 0
Providers Non-compliant after Round Completion (advancing) 6 0 0
Providers with Non-Reponses to ADRs for Round 2 0 0

Findings by State

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

Review decisions by state

Review decisions by state

Review decisions by state

Top Denial Reasons October 1, 2017 – September 30, 2019

  1. Face-to-Face missing/incomplete/untimely
  2. Initial certification invalid
  3. Therapy visits not medically necessary
  4. Recert estimate missing/invalid
  5. Plan of Care missing/invalid
    • FTF Documentation Denials accounted for approximately 28% of the total Targeted Probe and Educate denials.
    • Initial Certification Denials accounted for approximately 13% 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 8% 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

      ยท 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).
    • Plan of care missing/invalid 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 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).

Hospice

Probes completed October 1, 2017 – September 30, 2019

LOS with Non-Oncologic Diagnosis edit
Results 5D000
Round 1
5E000
Round 2
5F000
Round 3
Probes Completed 31 3 0
Providers Compliant after Round Completion 9 1 0
Providers Non-compliant after Round Completion (advancing) 22 2 0
Providers with Non-Reponses to ADRs for Round 5 0 0

LOS >180 Days edit
Results 5D002 5D007
Round 1
5E002 5E007
Round 2
5F002 5F007
Round 3
Probes Completed 2 1 0
Providers Compliant after Round Completion 1 1 0
Providers Non-compliant after Round Completion (advancing) 1 0 0
Providers with Non-Reponses to ADRs for Round 0 0 0

LOS >120 Days edit
Results 5D003
Round 1
5E003
Round 2
5F003
Round 3
Probes Completed 1 0 0
Providers Compliant after Round Completion 0 0 0
Providers Non-compliant after Round Completion (advancing) 1 0 0
Providers with Non-Reponses to ADRs for Round 0 0 0

LOS in LTC, NF or SNF edit
Results 5D004
Round 1
5E004
Round 2
5F004
Round 3
Probes Completed 1 1 0
Providers Compliant after Round Completion 0 1 0
Providers Non-compliant after Round Completion (advancing) 1 0 0
Providers with Non-Reponses to ADRs for Round 0 0 0

GIP LOC edit
Results 5D006
Round 1
5E006
Round 2
5F006
Round 3
Probes Completed 6 0 0
Providers Compliant after Round Completion 3 0 0
Providers Non-compliant after Round Completion (advancing) 3 0 0
Providers with Non-Reponses to ADRs for Round 0 0 0

Findings by State

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

Review decisions by state

Review decisions by state

Top Denial Reasons October 1, 2017 – September 30, 2019

  1. Terminal prognosis not supported
  2. Face-to-Face Encounter invalid
  3. Hospice plan of care invalid

Refer to the CGS Hospice Plan of Care and Hospice Denial Fact Sheet – Plan of CarePDF Web pages for documentation tips and access to the Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 9).

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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