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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-Responses 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-Responses 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-Responses to ADR’s for Round 1	3	3

Screen Shot

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-Responses to ADR’s for Round 1	0	0

Screen Shot

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-Responses to ADR’s for Round 1	2	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-Responses 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-Responses 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-Responses 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-Responses to ADR’s for Round 2	0	0

Screen Shot

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-Responses 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-Responses 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-Responses 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:

Documentation did not meet key components of the E/M service billed
- Fact sheets
Split/Shared not properly documented
- Split/Shared visits
  - Pub. 100-02, Chapter 15 Sections 60.1; 60.2; 60.3
  - Pub. 100-04, Chapter 12, Section 30.6.1B
Medical necessity was not documented appropriately
- SSA 1862 (a)(1)(A)
Nursing facility visits:
- Pub 100-4, Chapter 12, Section 30.6.13
- MLN Matters MM4246: Nursing Facility Services (Codes 99304-99318)
- Subsequent Nursing Facility Care (CPT Codes 99307-99310): Claim Submission and Documentation
- Reporting Federally Mandated Visits
- Physician Services in a Nursing Facility
  - 42 CFR Chapter IV §483.40
Critical Care Evaluation and Management Services
- PUB. 100-4, CH. 12, §30.6.12.
No documentation was received (non-response)
- SSA 1833(e)
Laboratory

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) 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:

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")

Q4 J15 Targeted Probe and Educate Status Update

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