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March 26, 2019

CGS Part B Reviews of Outpatient Psychotherapy Services

In March, CGS Administrators’ Targeted Probe and Education (TPE) Program implemented prepay review edits of outpatient psychotherapy services, including CPT codes 90832-90834, and 90836-90838 with and without concurrently billed Evaluation and Management (E/M) services. 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, CGS’ LCD L34353External Website provides guidance on psychotherapy services provided to both inpatients and outpatients, and by approved providers of services in outpatient settings.

CGS selects providers for the TPE process based on analysis of billing data indicating aberrancies that may suggest questionable billing.

CGS will mail notification letters to providers 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. The TPE process may consist of up to three rounds with a sample of 20-40 claims.  Providers may be released from a round contingent on if a provider’s error rate is within the compliance threshold.

Providers will be offered individualized education sessions after each round. 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 submit questions or request education via the J15 Part B TPE email box at J15BprobeandEducation@cgsadmin.com.

It is important for providers to comply with the additional documentation requests within 45 days of receipt to ensure that claims are reviewed timely.  Nonresponses could result in denials.

For more information on the TPE process, please access the links provided.  In addition, a link regarding additional documentation requests is included. 

As part of the TPE process, providers will receive results letters.

Please sign up for the myCGS portal for responding to additional documentation requests.

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