December 16, 2022
Targeted Probe and Educate Update: September 2021 – August 2022
Effective September 1, 2021, the Centers for Medicare & Medicaid Services (CMS) resumed the Targeted Probe & Educate (TPE) process. The information below describes the TPE program’s progress from September 2021 through August 2022.
Findings
Based on data analysis, Medical Review initiated complex review edits for specific providers that demonstrated a high risk for improper payment. CGS offered education throughout and upon completion of each round of TPE review. TPE results for Home Health and Hospice services are listed below.
Home Health
Probes Completed
Eligibility and Medical Necessity Edit
| Results | 5A006 Round 1 |
5A007 Round 1 |
5N000 Round 1 |
|---|---|---|---|
| Probes Completed | 10 | 16 | 26 |
| Providers Compliant after Round Completion | 3 | 0 | 5 |
| Providers Non-compliant after Round Completion (advancing) | 7 | 16 | 21 |
| Providers with Non-Responses to ADRs for Round | 3 | 3 | 0 |
Findings by State
Summary of review findings for providers that completed rounds (by State):
Top Denial Reasons
- Initial certification invalid
- SN not med necessary
- FTF missing/incomplete/untimely
- Documentation does not support homebound
- Therapy visits not med necessary
- Initial certification invalid accounted for 26.31% of the total TPE denials.
Refer to the CGS Home Health Physician or Allowed Practitioner Certification Date Web page for documentation tips and access to the Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 7). - Skilled nursing not medically necessary accounted for 25.86% of the total TPE denials.
Refer to the CGS Skilled Nursing in Home Health Care Web page for documentation tips and access to the Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 7). - FTF documentation denials accounted for 19.62% of the total TPE denials.
- The actual FTF encounter document was not submitted.
- CGS Home Health Face-to-Face (FTF) Encounter Web page
- The certifying physician did not document the date of the FTF encounter.
- The community physician was not identified when a physician who would not be following the patient after discharge signed the certification.
- No corroborating supporting documentation was incorporated.
- The required elements for initial certification (initial plan of care, initial certification, initial encounter documentation) were not submitted for recertification.
- The actual FTF encounter document was not submitted.
- Documentation does not support homebound accounted for 6.69% of the total TPE denials.
Refer to the Homebound Web page for documentation tips and access to the Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 7). - Therapy services not medically necessary accounted for approximately 6.69% of the total TPE 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.
- Initial certification invalid accounted for 26.31% of the total TPE denials.
Hospice
Probes Completed
Eligibility and Medical Necessity Edit
| Results | 5D000 Round 1 |
5D006 Round 1 |
5D008 Round 1 |
|---|---|---|---|
| Probes Completed | 5 | 2 | 13 |
| Providers Compliant after Round Completion | 1 | 2 | 5 |
| Providers Non-compliant after Round Completion (advancing) | 4 | 0 | 8 |
| Providers with Non-Responses to ADRs for Round | 0 | 0 | 0 |
Findings by State
Summary of review findings for providers that completed rounds (by State):
Top Denial Reasons
- Terminal prognosis not supported
- Notice of Election invalid
- Physician narrative missing/invalid
- MD services not medically necessary
- Face-to-Face Encounter invalid
- Terminal prognosis not supported accounted for 50.50% of the total TPE 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). - Notice of Election invalid accounted for 13.37% of the total TPE 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). - Physician narrative missing/invalid accounted for 8.91% of the total TPE denials.
Refer to the Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 9). - Physician services not medically necessary accounted for 7.43% of the total TPE denials.
Refer to the CGS Billing Hospice Physician and Nurse Practitioner (NP) Services Quick Resource Tool and Physician Services Web page for documentation tips and access to the Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 9). - Face-to-Face Encounter invalid accounted for approximately 7.43% of the total TPE denials.
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).
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 a webinar, web-based presentation, or traditional teleconference. 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
At the completion of Round 1/2, providers identified as non-compliant will advance to Round 2/3 of TPE at least 45 days from the 1:1 post-probe education call completion date. CGS offers provider education at any time, and you may request education even if you aren’t selected for TPE. CGS encourages providers to request education, conduct self-monitoring based on our posted Medical Review Activity Log, and use tools such as Comparative Billing Reports (CBRs) offered through our myCGS Web portal.
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