Quarterly TPE Update January 2020 – March 2020

J15 Targeted Probe and Educate Status Update

The J15 Part A Medical Review department initiated probe review edits for specific providers in Kentucky and Ohio identified through data analysis as demonstrating high risk for improper payment. Education has been offered to providers throughout, and upon completion of, Round 1 and Round 2 of the Targeted Probe and Educate (TPE) process.

This chart reflects probes completed January 1, 2020 – March 31, 2020:

Results	Kentucky	Ohio
Probes Completed	5	8
Providers Compliant after Round 1 Completion	3	6
Providers Non-compliant after Round 1 Completion	2	2
Providers with Non-Reponses to ADRs for Round 1	2	4

The results of the probes per edit are listed below for the period of January 1, 2020 – March 31, 2020:

5PE10 Round 1 Cataract Removal (HCPCS 66984, 66983, and 66982)

	Kentucky	Ohio
Probes Completed	0	1
Providers Compliant after Round 1 Completion	0	0
Providers Non-compliant after Round 1 Completion	0	1
Providers with Non-responses to ADRs for Round 1	0	1

Overall Claim Findings by State

Denial Code Breakdown:

Reason for Denial

5D164 – No Documentation of Medical Necessity

• Documentation submitted for review does not support the medical necessity of some of the services billed

56900 – Requested Records Not Submitted

• Medical records were not received in response to an ADR in the required time frame; therefore, unable to determine medical necessity and the claim was denied in the system

How to Prevent Denials:

Documentation to Include:

• Comprehensive ophthalmologic examination (Ophthalmology office visit)
  • Impairment in the ability to carry out activities of daily living (ADLs)
  • Record reflecting cataract is the primary cause of the decreased visual acuity and/or functional impairment or documentation to support visual impairment of 20/50 or worse or additional testing showing visual acuity decreased by two lines w/ consensual light testing or glare testing
• Operative report for correct eye and DOS inclusive of the correct modifier
• Medical necessity for use of CPT code 66982 – Complex procedure code
  • Documentation must support extra work/intensity of the physician during the procedure in order to support billing 66982 – Complex procedure code instead of simple procedure code 66984.
• The use of Trypan Blue in and of itself does not constitute sufficient extra work or intensity and the simple procedure code 66984 should be reported rather than the complex procedure code 66982
• When utilizing mechanical dilation (Ex. Malyugin Ring or Iris Hooks) during the procedure, the documentation should include the reason this is medically necessary and the proper complex procedure coding of CPT code 66982, not the simple procedure CPT code 66984
  
  CGS Local Coverage Determination (LCD): Cataract Extraction (L33954)

5PE13 Round 1 Review of SNF RUG Codes RUA, RUB, RUC, RUL, RUX, RVA, RVB, RVC, RVL and RVX

	Kentucky	Ohio
Probes Completed	3	6
Providers Compliant after Round 1 Completion	3	6
Providers Non-compliant after Round 1 Completion	0	0
Providers with Non-responses to ADRs for Round 1	1	2

Overall Claim Findings by State

Denial Code Breakdown:

Reason for Denial

5DOWN – Medical Review Downcode

• The services billed were paid at a lower payment level. Based on medical review, the documentation submitted for review did not meet the criteria for the RUG code(s) billed. As a result, reimbursement has been adjusted to a lower payment level

5D504 – Information Provided Does Not Support the Medical Necessity for This Service

• The claim was fully or partially denied, as documentation provided does not support the medical necessity for this service

56900 – Requested Records Not Submitted

• Medical records were not received in response to an ADR in the required time frame; therefore, unable to determine medical necessity and the claim was denied in the system

5H507 – SNF MDS is not in the National Repository

• The SNF MDS is not in the National Repository

5D505 – Certification not valid

• The certification or recertification for SNF admission was either not submitted for review or did not meet requirements for certification

How to Prevent Denials:

* Ensure that benefit days are available prior to submitting the request for payment to Medicare *

Documentation to Include:

• A clear picture of the beneficiary's medical condition that supports the data on the MDS and the RUG code(s) billed
• Completed Certification/Recertification inclusive of an estimation of how much time is required for skilled services signed and dated by physician or approved healthcare professional
• Therapy minutes and daily progress notes supporting RUG code for dos billed, including rolling 7 day period, and any "change of therapy" periods
• Interdisciplinary orders and evaluations
• SNF Minimum Data Set (MDS) in the national repository
  • Ensure that the MDS has been entered into the National Repository prior to submitting request for payment to Medicare
  • Ensure that the MDS clinical assessment includes data for all covered days associated with the billing period
    
    MCR Benefit Policy Manual 100-2, Chapter 8 SNF
    
    MLN SNF Billing Reference

5PE16 Round 1 Review of Outpatient Claims for Pulmonary Rehabilitation (HCPCS G0424)

	Kentucky	Ohio
Probes Completed	2	1
Providers Compliant after Round 1 Completion	0	0
Providers Non-compliant after Round 1 Completion	2	1
Providers with Non-responses to ADRs for Round 1	1	1

Overall Claim Findings by State

Denial Code Breakdown:

Reason for Denial

5D902/5H902 – Documentation did not Include Required Components

• The claim was fully or partially denied because the following components of the pulmonary rehabilitation program were not found in the submitted documentation:
  • Physician-prescribed exercise
  • Respiratory Risk Factor Modification (education or training)
  • Psychosocial assessment
  • Outcomes assessment
  • Individualized treatment plan

5D169/5H169 – Services not documented

• The claim was fully or partially denied because the provider billed for services/items not documented in the submitted medical record

56900 – Requested Records Not Submitted

• Medical records were not received in response to an ADR in the required time frame; therefore, unable to determine medical necessity and the claim was denied in the system

5D901/5H901 – Pulmonary Rehab Not Warranted for Diagnosis

• The claim was fully or partially denied as the condition required for coverage of pulmonary rehabilitation services was not submitted in the medical record
• Medicare coverage of pulmonary rehabilitation services is defined in the Code of Federal Regulations (42 CFR 410.47). Coverage for pulmonary rehabilitation items and services is limited to patients with moderate to very severe COPD (defined as GOLD classification II, III, and IV), when referred by the physician treating the chronic respiratory disease

How to Prevent Denials:

*Ensure services billed are coded accurately for the service provided and the documentation supports those services.

Documentation to Include:

• Individualized Treatment Planned (ITP) established, reviewed, signed and dated by physician every 30 days to cover the DOS billed. (Please note this may include an ITP completed 30 days prior to the DOS billed to be included within the medical record)
• All Pulmonary Rehabilitation Program Component Requirements
  • Physician-prescribed exercise
  • Pulmonary risk factor modification (including information on respiratory problem management, pulmonary risk factor modification, education, counseling and behavioral intervention tailored to meet the patient's individual needs)
  • Psychosocial assessment (a written evaluation of an individual's mental and emotional functioning as it relates to the individual's rehabilitation or respiratory condition)
  • Outcomes assessment (patient-centered outcomes and effectiveness to determine the result of the interventions)
  • ITP
• Clear documentation of total session minutes provided for DOS billed (Documentation must indicate at least 31 minutes for 1 billed session or 91 minutes for 2 billed sessions)
• Physician prescribed exercise (some aerobic exercise must be included in each session) will include:
  • Mode of exercise (typically aerobic)
  • Target intensity (e.g., a specified percentage of the maximum predicted heart rate, or number of METs)
  • Duration of each session (e.g., "20 minutes")
  • Frequency (number of sessions per week)
• Pulmonary function test (PFT) submitted in order to validate the diagnosis of moderate to very severe COPD as per the GOLD classification (Stage II, III, or IV). The FEV1/FVC must be < 70% and FEV1 must be < 80% and must meet both criteria.

*The program component requirements must be signed and dated by the physician every 30 days. These components may be separate or compiled together in the ITP*

*Medicare covers pulmonary rehabilitation items and services for patients with moderate to very severe COPD (defined as GOLD classification II, III, and IV), when referred by the physician treating the chronic respiratory disease*

MCR Claims Processing Manual, Chapter 32 Pulmonary Rehab section 140.4

MCR Benefit Policy Manual Chapter 15 Pulmonary Rehab

42 CFR 410.47 – Pulmonary rehabilitation program: Conditions for coverage

Pulmonary Rehabilitation Coverage and Documentation Requirements Article

To learn more about the Targeted Probe & Education process, please refer to the following links:

• CGS Part A TPE Page
• Navigating the Process: TPE Educational Video
• Targeted Probe and Educate (TPE) – Centers for Medicare & Medicaid Services

Please submit all documentation as required in the LCD or NCD if applicable and in accordance with the Medicare Benefit Policy Manual. Avoid 56900 denials by ensuring all the required documentation is submitted for review, the information is accurate and that the claim was billed timely (within 45 days) in response to an Additional Documentation Request (ADR). It is the responsibility of the provider to submit complete and accurate documentation per the regulatory guidelines for each claim. In order to meet the policy requirements for each claim submitted, please refer to ADR (Additional Documentation Request) received and visit the links provided for additional information specific to each edit.

• CMS Medicare Program Integrity Manual (Pub. 100-08), Chapter 3, Section 3.3.2.4
• CMS MLN Matters Article MM6698, Signature Guidelines for Medical Review Purposes
• Definition of "medically necessary": Social Security Act (SSA), Section 1862 (a)(1)(A)

Next Steps:

Providers found to be non-compliant at the completion of Round 1/2 will advance to Round 2/3 of TPE within 45 days of completion of the post probe educational session. CGS offers education at any time for providers regardless of identification for TPE. Part A Providers may submit questions or request education via the Part A TPE email box (Please include the facility name, Provider Number/PTAN, and the edit reason code/audit in place within your facility in the subject of your email or inquiry to facilitate any communication): J15AprobeandEducation@cgsadmin.com

CGS encourages providers to request education and conduct self-monitoring based on our posted Medical Review activity and using tools such as Comparative Billing Reports (CBRs) offered through our web portal.

• Comparative Billing Reports (CBRs) Job Aid – Part A

To learn more about the Targeted Probe & Education process, please refer to the following links:

• Targeted Probe and Educate (TPE)
• Video Education: Targeted Probe and Educate (TPE)
• Targeted Probe and Educate (TPE) – Centers for Medicare & Medicaid Services