February 26, 2020
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 October 1, 2017 – December 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 October 1, 2017 – December 31, 2019
Eligibility and Medical Necessity edit
| Results | 5A000 Round 1 |
5B000 Round 2 |
5C000 Round 3 |
|---|---|---|---|
| Probes Completed | 388 | 205 | 2 |
| Providers Compliant after Round Completion | 51 | 87 | 1 |
| Providers Non-compliant after Round Completion (advancing) | 337 | 118 | 1 |
| Providers with Non-Responses to ADRs for Round | 80 | 19 | 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-Responses 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-Responses 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 | 33 | 0 |
| Providers Compliant after Round Completion | 5 | 19 | 0 |
| Providers Non-compliant after Round Completion (advancing) | 60 | 14 | 0 |
| Providers with Non-Responses to ADRs for Round | 30 | 6 | 0 |
Low Visit Utilization edit
| Results | 5A005 Round 1 |
5B005 Round 2 |
5C005 Round 3 |
|---|---|---|---|
| Probes Completed | 12 | 0 | 0 |
| Providers Compliant after Round Completion | 5 | 0 | 0 |
| Providers Non-compliant after Round Completion (advancing) | 7 | 0 | 0 |
| Providers with Non-Responses 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.
Top Denial Reasons October 1, 2017 – December 31, 2019
- Face-to-Face missing/incomplete/untimely
- Initial certification invalid
- Therapy visits not medically necessary
- Recert estimate missing/invalid
- Plan of Care missing/invalid
- FTF Documentation Denials accounted for approximately 28% of the total Targeted Probe and Educate denials.
- Actual FTF encounter document not submitted
- CGS Home Health Face-to-Face (FTF) Encounter Web page
- 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
- No corroborating supporting documentation incorporated
- 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.
- Actual FTF encounter document not submitted
- Initial Certification Denials 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 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. - 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 Certification Web pages for documentation tips and access to the Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 7). - 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).
- FTF Documentation Denials accounted for approximately 28% of the total Targeted Probe and Educate denials.
Hospice
Probes completed October 1, 2017 – December 31, 2019
LOS with Non-Oncologic Diagnosis edit
| Results | 5D000 Round 1 |
5E000 Round 2 |
5F000 Round 3 |
|---|---|---|---|
| Probes Completed | 39 | 5 | 0 |
| Providers Compliant after Round Completion | 12 | 2 | 0 |
| Providers Non-compliant after Round Completion (advancing) | 27 | 3 | 0 |
| Providers with Non-Responses 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-Responses 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-Responses 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-Responses 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-Responses to ADRs for Round | 0 | 0 | 0 |
New Providers edit
| Results | 5D008 Round 1 |
5E008 Round 2 |
5F008 Round 3 |
|---|---|---|---|
| Probes Completed | 2 | 0 | 0 |
| Providers Compliant after Round Completion | 0 | 0 | 0 |
| Providers Non-compliant after Round Completion (advancing) | 2 | 0 | 0 |
| Providers with Non-Responses 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.
Top Denial Reasons October 1, 2017 – December 31, 2019
- Terminal prognosis not supported
- Face-to-Face Encounter invalid
- Notice of Election invalid
- Hospice plan of care invalid
- Terminal prognosis not supported accounted for approximately 67% 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). - Face-to-Face Encounter Denials accounted for approximately 6% of the total Targeted Probe and Educate denials.
Refer to the CGS Hospice Face-to-Face (FTF) Encounter and Hospice Denial Fact Sheet – Face-to-Face Encounter is Missing/Incomplete/Untimely Web pages for documentation tips and access to the Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 9). - Notice of Election is invalid accounted for approximately 6% 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). - Hospice plan of care invalid accounted for approximately 6% of the total Targeted Probe and Educate denials.
Refer to the CGS Hospice Plan of Care and Hospice Denial Fact Sheet – Plan of Care 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 67% 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.
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