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: + | –

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	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-Reponses 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-Reponses 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-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

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-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:

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

spacer