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

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

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Targeted Probe and Educate: Did You Know?

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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?

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