Corporate

October 30, 2018 - Revised 02.08.19

CGS Part B Reviews of Frequency of E/M Office Visits

CGS Administrators' Targeted Probe and Education (TPE) Program will begin post-pay reviews of subsequent Evaluation and Management (E/M) services in October, 2018 in an effort to determine medical necessity of follow-up visit frequency and associated repetitive urine drug testing (such as screening for detection of Opiates/Benzodiazepines).

Guidance for E/M service provision and documentation may be found in the CMS Medicare Learning Document publication "Evaluation and Management Services Guide [ICN 006764]"External PDF.

In addition, the CGS Administrators' LCD L36029External Website provides guidance on the use and medical necessity of Urine Drug Testing.

CGS selects providers for the TPE process based on the following:

  • Analysis of billing and other Medicare data indicating aberrancies that may suggest questionable billing practices; or
  • Currently on targeted review and are transitioned to the TPE process based on error rate results; or
  • On service specific review error rate results.

CGS will focus on review of policies associated with frequency of drug screening and regulatory requirements associated with billing of evaluation and management services as stated above. CGS will not review prescribing of opioids nor treatment of beneficiaries with opioids.

CGS will mail a letter to those who have been selected for TPE review. The letter will outline the reason for selection, and will provide an overview of the TPE process and contact information.

TPE consists of up to three rounds of review with up to 20-40 claims selected (pre or post payment) with each round. Subsequent rounds will begin 45-56 days after individual provider education is completed. Discontinuation of review may occur if appropriate improvement, and error rate below the target threshold is achieved during the review process.

For Post-pay reviews, an Additional Documentation Request (ADR) letter will be sent with a list of sampled claims attached. CGS has 60 days from the date that all of the documentation is received to review and make payment decisions. Refer to the Medical Review Additional Development Request (ADR) Process Web page to learn how to check if an ADR was generated for your claim.

No response to ADRs will count as an error when calculating the error rate.

A letter with the review results will be mailed at the conclusion of each round. The 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.

Providers with a moderate to high error rate will be offered an individualized education session where each claim found in error may be discussed and any questions will be answered. CGS offers education sessions via webinar, web-based presentation, or traditional teleconferences. Other methods may also be available. Providers may also submit questions or request education via the 15 Part B TPE email box at J15BProbeandEducation@cgsadmin.com.

If high denial rates continue after 3 rounds of TPE, CGS will send a referral to CMS for additional action.

For more information on Targeted Probe and Education, please see the following links:

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