May 20, 2024
Targeted Probe & Educate Update: January – March 2024
The information below describes the CGS J15 Home Health & Hospice Targeted Probe & Educate (TPE) program's progress from January through March 2024.
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 if medical record documentation supports 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, J44.0, J44.1, J44.81, J44.89, J44.9, (J44, J44.8 discontinued 10.01.2023), I10, G20.A1, G20.A2, G20.B1, G20.B2, G20.C, (G20 discontinued 10.01.2023), 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, J44.0, J44.1, J44.81, J44.89, J44.9, (J44, J44.8 discontinued 10.01.2023), I10, G20.A1, G20.A2, G20.B1, G20.B2, G20.C, (G20 discontinued 10.01.2023), I25.10, N39.0, J18.9, or I87.2. | TPE Round 1 Postpayment Round 2 Prepayment Round 3 Prepayment |
Results
| Results | 5A007 Round 1 | 5B007 Round 2 | 5B006 Round 2 | 5C006 Round 3 | 5T000 Round 2 |
|---|---|---|---|---|---|
| Probes Completed | 5 | 13 | 5 | 1 | 3 |
| Providers Compliant after Round Completion | 1 | 3 | 4 | 0 | 2 |
| Providers Non-compliant after Round Completion (advancing) | 4 | 10 | 1 | 1 | 1 |
| Providers with Non-Reponses to ADRs for Round | 1 | 0 | 1 | 0 | 1 |
| Education contacts | 3 | 17 | 1 | 1 | 3 |
Findings by State
Summary of review findings for providers that completed rounds of review (by State):
Top Denial Reasons
- Skilled nursing not medically necessary (5HN18)
- Initial certification invalid (5HC09)
- Therapy visits not medically necessary (5HY01)
- F2F missing/incomplete/untimely (5HC01)
- Medical records not received (56900)
- Skilled nursing not medically necessary accounted for 26.6% 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).
- Initial certification invalid accounted for 18.2% of the total TPE 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).
- Therapy visits not medically necessary accounted for approximately 17.3% 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), and the Local Coverage Determination for physical therapy services.
- F2F missing/incomplete/untimely accounted for 16.1% of the total TPE denials.
- o Actual F2F encounter document not submitted – See the CGS Home Health Face-to-Face (FTF) Encounter Web page.
- o Certifying physician did not document the date of the F2F encounter – See the CGS Home Health Physician Certification Web page.
- o Community physician was not identified when a physician who would not be following the patient after discharge signed the certification.
- o No corroborating supporting documentation incorporated – See the CGS Incorporating Home Health Agency Documentation into the Physician's Medical Record: Supporting Eligibility with Home Health Agency Clinician Notes Web page.
- o Required elements for initial certification (initial plan of care, initial certification, initial encounter documentation) not submitted for recertification – See the CGS Home Health Coverage Guidelines Web page.
- Medical records not received accounted for 6.8% of the total TPE denials.
Refer to the CGS Home Health Top Medical Denial Reason Codes Web page for tips.
Hospice Probes Completed
Current Edits
The primary focus of these reviews is to determine if 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 with length of stay (LOS) >730 days and non-oncologic diagnosis code | TPE Prepayment Review |
| GIP LOC | 5D006 5E006 5F006 | This edit selects hospice providers who submitted claims with revenue code 0656 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 have submitted at least 50 claims. | TPE Prepayment Review |
| LOS 313-515 days | 5D010 5E010 5F010 | This edit selects hospice providers who submitted claims with length of stay (LOS) >730 days and non-oncologic diagnosis code | TPE Prepayment Review |
Results
| Results | 5D008 Round 1 | 5E008 Round 2 | 5D010 Round 1 | 5E010 Round 2 | 5D006 Round 1 | 5E000 Round 2 |
|---|---|---|---|---|---|---|
| Probes Completed | 6 | 10 | 13 | 1 | 1 | 3 |
| Providers Compliant after Round Completion | 1 | 6 | 0 | 0 | 1 | 1 |
| Providers Non-compliant after Round Completion (advancing) | 5 | 4 | 13 | 1 | 0 | 2 |
| Providers with Non-Reponses to ADRs for Round | 0 | 0 | 2 | 0 | 0 | 1 |
| Education Contacts | 13 | 10 | 21 | 1 | 2 | 5 |
Findings by State
Summary of review findings for providers that completed rounds of review (by State):
Top Denial Reasons
- Notice of Election invalid (5PX06)
- Terminal prognosis not supported (5PM01)
- Face-to Face encounter invalid (5PC08)
- Medical records not received (56900)
- Physician narrative missing/invalid (5PC01)
- Notice of Election invalid accounted for 45.2% of the total TPE denials; NOE not present accounted for 1.2% 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).
- Terminal prognosis not supported accounted for 38.7% 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). - Face-to-Face encounter invalid accounted for approximately 5.6% of the total TPE 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). - Medical records not received accounted for 3.3% of the total TPE denials.
Refer to the CGS Home Health Top Medical Denial Reason Codes Web page for tips.
- Physician narrative missing/invalid accounted for 1.4% of the total TPE denials.
Refer to the CGS Hospice Certification / Recertification Requirements Web page for documentation tips and access to the Medicare Benefit Policy Manual (CMS Pub. 100-02), Ch. 9, §20.1.
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 Medical Review Activity Log, and use tools such as Comparative Billing Reports (CBRs) offered through our myCGS portal.
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