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February 4, 2019

Q4 J15 Targeted Probe and Educate Status Update

October 1, 2018- December 30, 2018

Medical Review initiated the Targeted Probe and Educate (TPE) process on October 1, 2017 per CR10249. TPE probe edits are initiated for specific providers identified through data analysis demonstrating high risk for improper payment. Intra-probe education is offered to providers throughout, and post probe education is offered upon completion of Round 1 and initiation of Rounds 2 and 3 of the Targeted Probe and Educate process. Medical Review initiated 84 provider edits during the period of October 1, 2018 through December 31, 2018. Seven providers progressed to Round 2 and two providers progressed to Round 3. The chart below lists numbers of completed probes between October 1, 2017-December 31, 2018. As of December 31, 2018, there was a total of 151 TPE provider active edits in place.

Results

Kentucky

Ohio

Probes Completed

28

24

Providers Compliant after Round 1 Completion

9

9

Providers Non-compliant after Round 1 Completion

19

15

Providers with Non-Reponses to ADR’s for Round 1

13

7

This chart reflects probes completed between October 1, 2018 and December 30, 2018

Results

Kentucky

Ohio

Probes Completed

9

9

Providers Compliant after Round 1 Completion

6

10

Providers Non-compliant after Round 1 Completion

13

5

Providers with Non-Reponses to ADR’s for Round 1

9

2

The results of the Probes per Strategy are listed below:

Strategy: Ambulance- Round 1

Results

Kentucky

Ohio

Probes Completed

7

7

Providers Compliant after Round 1 Completion

2

1

Providers Non-compliant after Round 1 Completion

5

6

Providers with Non-Reponses to ADR’s for Round 1

3

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Findings:

  • Documentation did not support that beneficiary could not be transported by any other means.
  • Conditions listed on Provider Certification Statement (PCS) regarding medical necessity for the service were not reflected in the documentation by ambulance personnel.
  • PCS forms were not signed by the beneficiary’s primary care physician and were instead signed by ancillary staff.

Strategy: Home Visits – Round 1

Results

Kentucky

Ohio

Probes Completed

1

0

Providers Compliant after Round 1 Completion

0

0

Providers Non-compliant after Round 1 Completion

1

0

Providers with Non-Reponses to ADR’s for Round 1

0

0

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Findings:

  • Documentation did not support medical necessity of the service or the reason the service was provided in the home instead of in a traditional office setting.
  • Documentation did not meet required Evaluation and Management guidelines for the level of service billed.

Strategy: Hospital Visits- Round 1

Results

Kentucky

Ohio

Probes Completed

3

3

Providers Compliant after Round 1 Completion

0

1

Providers Non-compliant after Round 1 Completion

3

2

Providers with Non-Reponses to ADR’s for Round 1

0

Screen Shot

Findings:

  • Not meeting the key components required for billing CPT 99233, specifically lack of detailed history and medical decision making of high complexity.
  • Medical necessity for subsequent visits not clearly documented.
  • Failure to provide required documentation as requested
  • Visit billed by wrong provider.
  • Split/Shared visit billed with no documentation of significant face-to-face by provider.

Strategy: Nursing Facility Visits- Round 1

Results

Kentucky

Ohio

Probes Completed

1

1

Providers Compliant after Round 1 Completion

0

0

Providers Non-compliant after Round 1 Completion

1

1

Providers with Non-Reponses to ADR’s for Round 1

1

1

Screen Shot

Findings:

  • Handwriting illegible and no attestation provided.
  • Documentation did not support that a face-to-face examination occurred between the provider and the patient.
  • Provided plans of care illegible or dated months prior to visits without updates.
  • Documentation did not support required elements of code billed.

Strategy: Critical Care – Round 2

Results

Kentucky

Ohio

Probes Completed

0

1

Providers Compliant after Round 2 Completion

0

1

Providers Non-compliant after Round 2 Completion

0

0

Providers with Non-Reponses to ADR’s for Round 2

0

0

Screen Shot

Findings:

  • Requested documentation not received
  • Documentation did not indicate critical care time at bedside
  • Teaching provider did not use GC Modifier

Strategy: Emergency Room – Round 2

Results

Kentucky

Ohio

Probes Completed

2

0

Providers Compliant after Round 2 Completion

2

0

Providers Non-compliant after Round 2 Completion

0

0

Providers with Non-Reponses to ADR’s for Round 2

1

0

Screen Shot

Findings:

  • Documentation did not support level of service billed.

Strategy: Home Visits-Round 2

Results

Kentucky

Ohio

Probes Completed

2

0

Providers Compliant after Round 2 Completion

0

0

Providers Non-compliant after Round 2 Completion

2

0

Providers with Non-Reponses to ADR’s for Round 2

0

0

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Findings:

  • Frequency of visits not justified in documentation
  • Medical necessity of monthly visits for stable chronic conditions not clear in the documentation
  • Documentation did not support the level of service billed
  • Documentation not received

Strategy: Hospital Visits-Round 2

Results

Kentucky

Ohio

Probes Completed

6

9

Providers Compliant after Round 2 Completion

2

5

Providers Non-compliant after Round 2 Completion

4

4

Providers with Non-Reponses to ADR’s for Round 2

4

2

Screen Shot

Findings:

  • Documentation does not support split/shared criteria
  • Not meeting elements for level of service billed
  • Documentation not received
  • Documentation did not support medical necessity for the visit
  • Lack of GC Modifier use by teaching physicians indicating supervision of student

Strategy: Nursing Facility Visits-Round 2

Results

Kentucky

Ohio

Probes Completed

3

0

Providers Compliant after Round 2 Completion

1

0

Providers Non-compliant after Round 2 Completion

2

0

Providers with Non-Reponses to ADR’s for Round 2

2

0

Screen Shot

Findings:

  • Not meeting minimal components of visits billed
  • Not meeting guidelines for Federally Mandated visits
  • Seen frequently without documentation of an acute problem or support of medical necessity

Strategy: Office Visits-Round 2

Results

Kentucky

Ohio

Probes Completed

2

3

Providers Compliant after Round 2 Completion

2

1

Providers Non-compliant after Round 2 Completion

0

2

Providers with Non-Reponses to ADR’s for Round 2

0

1

Screen Shot

Findings:

  • Seen frequently without documentation to support medical necessity
  • Modifier 25 used to bill E/M visit in addition to a procedure without a separately identified problem

How to Prevent Denials:

Next Steps:

Providers found to be non-compliant at the completion of Round 1 will advance to Round 2 and those found to be non-compliant at the completion of Round 2 will advance to Round 3 of TPE at least 45 days after completion of the post probe educational session.  All providers under TPE review will be offered education at the end of each round.  Providers do not have to be identified for TPE to request education. Part B Providers may submit TPE questions or request education via the Part B TPE email box (Please include your Provider Number in the subject of the email):

J15BProbeandEducation@cgsadmin.com

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

We would also like to encourage providers to register for the myCGS portal.  Please access the preceding link to learn more about this process and its benefit to you. 

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

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