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Impact

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June 14, 2023

Targeted Probe and Educate Update: September 2022 – March 2023

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 2022 through March 2023.

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

Current Edits

The primary focus of these reviews is to determine whether the medical record documentation supports the Medicare guidelines for medical necessity of the services billed. Current home health edits for TPE include:

Review Topic

Edit Numbers

Description

Review Type

Medical Necessity

5A007

5B007

5C007

This edit selects providers who submitted home health claims with 2 to 6 visits and diagnosis code I11.0, Z46.6, J44.1, I10, J44.9, G20, I25.10, N39.0, J18.9, or I87.2.

TPE Prepayment Review

New Providers

5A006

5B006

5C006

This edit selects home health claims for relatively new providers who have submitted at least 50 claims.

TPE Prepayment Review

Medical Necessity

5N000

5T000

5V000

This edit selects providers who submitted home health claims with 2 to 6 visits and diagnosis code  I11.0, Z46.6, J44.1, I10, J44.9, G20, I25.10, N39.0, J18.9, or I87.2.

TPE

Round 1 Postpayment

Round 2 Prepayment

Round 3 Prepayment

Results

Results

5A006

Round 1

5A007

Round 1

5N000

Round 1

5B006

Round 2

5B007

Round 2

# of Provider Probes Completed

24

99

24

2

3

# of Compliant Providers

1

2

4

1

0

# of Non-Compliant Providers

23

97

20

1

3

# of Providers with Non-Responses to ADRs

9

9

0

0

0

Education Contacts

97

195

65

2

3

Findings by State

Summary of review findings for providers that completed rounds of review (by State):

Round 1 review decisions

Top Denial Reasons

  1. Skilled nursing not medically necessary (5HN18)
  2. Initial certification invalid (5HC09)
  3. FTF missing/incomplete/untimely (5HC01)
  4. Therapy visits not medically necessary (5HY01)
  5. Documentation does not support homebound (5HH01)

Hospice Probes Completed

Current Edits

The primary focus of these reviews is to determine whether the medical record documentation supports the Medicare guidelines for medical necessity of the services billed. Current hospice edits for TPE include:

Review Topic

Edit Numbers

Description

Review Type

LOS with Non-Oncologic Diagnosis

5D000

5E000

5F000

This edit selects hospice providers who submitted claims for a length of stay (LOS) >730 days with a non-oncologic diagnosis code.

TPE Prepayment Review

GIP LOC

5D006

5E006

5F006

This edit selects hospice providers who submitted claims with revenue code 0656 and units greater than or equal to 7 days.

TPE Prepayment Review

New Providers

5D008

5E008

5F008

This edit selects hospice claims for relatively new providers who submitted at least 50 claims.

TPE Prepayment Review

LOS 313-515 days

5D010

5E010

5F010

This edit selects hospice providers who submitted claims for a length of stay (LOS) 313-515 days.

TPE Prepayment Review

Results

Results

5D000

Round 1

5D006

Round 1

5D008

Round 1

5D010

Round 1

# of Provider Probes Completed

7

5

20

10

# of Compliant Providers

0

0

0

0

# of Non-Compliant Providers

7

5

20

10

# of Providers with Non-Responses to ADRs

0

0

1

2

Education Contacts

15

21

71

21

Findings by State

Summary of review findings for providers that completed rounds of review (by State):

Round 1 review decisions

Top Denial Reasons

  1. Terminal prognosis not supported (5PM01)
  2. Notice of Election invalid (5PX06)
  3. NOE not present (5PX07)
  4. Certification missing (5PC02)
  5. Face-to-Face Encounter invalid (5PC08)

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 webinar, web-based presentation, or traditional teleconference. Other methods may also be available. Providers may also submit questions or request education via email: 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.

References

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