License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA website.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

AMA Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED "I ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "I DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. License to use CDT-4 for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association website.
Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. Please click here to see all U.S. Government Rights Provisions.
ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT-4 is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT-4. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT-4 and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third-party beneficiary to this Agreement.
CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT-4 should be addressed to the ADA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT-4. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I ACCEPT". If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must click below on the button labeled "I DO NOT ACCEPT" and exit from this computer screen.

Print | Bookmark | Email | Font Size: + | –

Targeted Probe and Educate: Did You Know?

Click on an item to expand or Show All / Close All

What is Targeted Probe and Educate (TPE)?
- As a Medicare Administrative Contractor (MAC), CGS Administrators, LLC is required by the Centers for Medicare & Medicaid Services (CMS) to analyze claims payment data in order to identify areas with the greatest risk of inappropriate program payment. CMS has authorized Jurisdiction 15 to conduct the Targeted Probe and Educate (TPE) review process.
  
  The purpose of the claim review is to ensure documentation supports the reasonable and necessary criteria of the services billed and follows Medicare rules and regulations. The Targeted Probe and Educate Review process is typically repeated for up to three rounds, but may involve additional rounds at CMS direction.
  
  Reviewed 9/16/2021
How and why was I selected?
- - Providers are selected based on analysis of billing data indicating aberrancies that may suggest questionable billing practices.
    
    OR
  - Provider was already on targeted review and transitioned to TPE based on error rate results.
    
    OR
  - Provider error rate results based on service specific review.
  Reviewed 9/16/2021
How many claims will be selected?
- A span of 20-40 pre or post payment claim samples will be selected for review with each round. Your notification and additional documentation request (ADR) letter or system notification will indicate if the sample is pre-payment or post-payment.
  
  Reviewed 9/16/2021
How will I know if we are selected for targeted probe and educate review?
- Providers will be notified via letter of selection for TPE. The letter will outline reason for selection, overview of TPE process, and contact information.
  
  Reviewed 9/16/2021
How long does each round last?
- The length of the round is dependent upon the provider's response to the ADR. Providers who do not respond to ADR requests will be contacted. Non-responses to ADRs will count as an error when calculating the error rate. Subsequent Rounds will begin 45-56 days after education is completed.
  
  Example:
  Round 1 Educational Call completed on 11/1/2017
  Round 2 TPE will begin as early as 12/16/2017
  
  Upon completion of each round of review, providers will be offered an individualized educational session. During this education session, an educator will walk through each claim found to be in error, as well as answer any questions regarding the policy or the TPE process. CGS offers webinars, which are web-based presentations using internet technology, and traditional teleconferences. We can offer other methods of direct communication if these methods are not convenient.
  
  Reviewed 9/16/2021
What information do I need to submit with the additional documentation request (ADR)?
- An ADR letter or system notification will be sent on claims selected for review. This letter/notification will include a list of specific elements needed to support the service on review. Please ensure the process for routing these documents to the person(s) responsible for submission is timely and effective. Inform your staff responsible for receiving the ADR letters and submitting the required documentation for this review. Authorization for the collection of this information is included in Federal Law at SSA 1833 (e) and in Federal Regulation at 42 CFS 424.5(a)(6).
  
  For more information about submission of ADRs, visit myCGS MR ADR Job Aid and Additional Documentation Requests (ADRs): How and What to Send
  
  Reviewed 9/16/2021
How will I be notified of my results?
- Upon completion of the probe review sample, a letter will be mailed with the results of all claims reviewed. Providers can also access the payment system or myCGS, the CGS web portal for information regarding the payment or denial of the claim.
  
  Reviewed 9/16/2021
When will I receive my results?
- Medical Review will provide you written notification at the end of the review to include your results. This letter will include the number of claims reviewed, the number of claims allowed in full, the number of claims denied in full or in part and limited education on the results.
  
  Reviewed 9/16/2021
What happens after each round of review?
- The TPE review process is typically repeated for up to three rounds, but may involve additional rounds at CMS direction. If there are continued high error rates after three rounds, CGS will refer the provider to CMS for additional action, which may include additional rounds of TPE, 100% prepay review, extrapolation, referral to a Recovery Auditor, etc. Discontinuation of review may occur if appropriate improvement, or an error rate below the target threshold is achieved during the review process.
  
  Reviewed 9/16/2021

How can I request education?

Part A	J15APROBEANDEDUCATION@cgsadmin.com
Part B:	J15BPROBEANDEDUCATION@cgsadmin.com
HHH:	J15HHPROBEANDEDUCATION@cgsadmin.com

Reviewed

9/16/2021

What if I have questions while under review?
- If you have any questions regarding this information, please contact the Provider Contact Center at the toll free number below for your provider type.
  - Home Health/Hospice – 1.877.299.4500
  - Part A – 1.866.590.6703
  - Part B – 1.866.276.9558
  Should a pattern of findings be noted during the course of review, providers may be contacted by a CGS educator for interim education.
  
  Reviewed 9/16/2021
Can I appeal these claims?
- When claim is denied with message codes CO50 and M127 indicating that the medical documentation was not received by CGS, or was not received timely, a reopening may be requested to have the Medical documentation reviewed.
  
  The reopening form is located in myCGS Forms or on the CGS website. The link to the form is: https://cgsmedicare.com/partb/forms/index.html#reopenings
  
  Denied claims cannot be resubmitted or adjusted since a payment determination cannot be altered other than by appeal or reconsideration. Please see Medicare Claims Processing Manual, Publication 100-04, Chapter 1, Section 60.1.
  
  Reviewed 9/16/2021
How are error rates calculated?
- A payment error rate and claims error rate will be provided as follows:
  
  Payment error rate is calculated by dividing the allowed dollars in error divided by allowed dollars.
  
  Example: $1000/$2000 = 50% Payment error rate
  
  Claim error rate is calculated by dividing the number of claims in error (includes denied/reduced) by total claims reviewed.
  
  Example: 10/20 = 50% Claims error rate
  
  Reviewed 9/16/2021
How are review topics/issues selected?
- Review topics are selected based on data analysis identifying high risk areas for improper payment. These areas are outlined in the MAC's Improper Payment Reduction Strategy, which is reviewed and approved by CMS. Review topics may also be directed per CMS instruction. CGS lists active review topics in the MR Activity Log.
  
  Reviewed 9/16/2021
When will Targeted Probe and Educate reviews resume?
- TPE will resume September 1, 2021.
  
  Reviewed 9/16/2021
How will we know if we are resuming Targeted Probe and Educate review?
- Selected providers will be notified via letter of TPE selection. The letter will outline the reason for selection and include an overview of the TPE process and contact information.
  
  Published: 9/16/2021
What round of Targeted Probe and Educate will resume?
- All TPE rounds underway prior to the Public Health Emergency are closed. Closure does not exempt providers from future TPE review activity. Selected providers will begin TPE in Round 1 regardless of the round they were in when TPE was paused.
  
  Published: 9/16/2021

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

AMA Disclaimer of Warranties and Liabilities.

CMS Disclaimer

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

Targeted Probe and Educate: Did You Know?

spacer