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May 28, 2019

J15 Targeted Probe and Educate Status Update Q1 January 1, 2019 – March 31, 2019

Medical Review initiated the Targeted Probe and Educate (TPE) process on October 1, 2017 per CR10249. TPE probe edits were initiated for specific providers identified through data analysis demonstrating high risk for improper payment and previous probe and targeted reviews. Education has been offered to providers throughout, and upon completion of, Round 1 and initiation of Rounds 2 and 3 of the Targeted Probe and Educate process. Medical Review initiated 39 prepay/postpay provider edits during the period of January 1, 2019 through March 31, 2019. 'Thirty-one probes were completed during this timeframe. Twelve providers progressed to Round 2 based on previous probe or targeted review results. Five providers progressed to Round 3. The chart below lists numbers of completed probes between October 1, 2017-March 31, 2019.

Results Kentucky Ohio
Probes Completed 37 46
Providers Compliant after Round 1 Completion 13 13
Providers Non-compliant after Round 1 Completion 21 30
Providers with Non-Reponses to ADRs for Round 1 16 16

This chart reflects probes completed between January 1, 2019 and March 31, 2019

Results Kentucky Ohio
Probes Completed 9 22
Providers Compliant after Round Completion 7 3
Providers Non-compliant after Round Completion 2 10
Providers with Non-Reponses to ADRs 3 9

This chart reflects Round 1 probes completed between January 1, 2019 and March 31, 2019

Results Kentucky Ohio
Probes Completed 6 13
Providers Compliant after Round 1 Completion 4 3
Providers Non-compliant after Round 1 Completion 2 10
Providers with Non-Reponses to ADRs for Round 1 1 4

The results of the Probes per Strategy are listed below:

Strategy: Ambulance- Round 1

Results Kentucky Ohio
Probes Completed 1 2
Providers Compliant after Round 1 Completion 1 0
Providers Non-compliant after Round 1 Completion 0 2
Providers with Non-Reponses to ADRs for Round 1 0 1

Probe Results

Findings:

  • Documentation did not support that beneficiary could not be transported by any other means.
  • Documentation did not clearly state the reason for a hospital to hospital transport.
  • Trip documentation did not meet guideline criteria for Specialty Care Transport.
  • PCS forms were not signed by the beneficiary's primary care physician and were instead signed by ancillary staff.
  • Conflicting information noted within run sheets regarding medical necessity for ambulance transport.

Strategy: Hospital Visits - Round 1

Results Kentucky Ohio
Probes Completed 1 2
Providers Compliant after Round 1 Completion 0 0
Providers Non-compliant after Round 1 Completion 1 2
Providers with Non-Reponses to ADRs for Round 1 0 1

Probe Results

Findings:

  • Not meeting the key components required for billing CPT level selected, specifically lack of history components and complexity of medical decision making.
  • 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 visit on the same date of service by billing provider.

Strategy: Nursing Home Visits- Round 1

Results Kentucky Ohio
Probes Completed 0 1
Providers Compliant after Round 1 Completion 0 0
Providers Non-compliant after Round 1 Completion 0 1
Providers with Non-Reponses to ADRs for Round 1 0 0

Probe Results

Findings:

  • Hospice patients being seen by primary care physician instead of hospice physician for hospice-condition related issues.
  • Documentation did not support that patient was seen for an acute complaint. Physician providing routine, frequent visits without documented medical necessity for the service.
  • Documentation did not support required elements of code billed.
  • Significant carryover information from visit to visit. Acute reason for visit not clear.

Strategy: Office Visits Round 1

Results Kentucky Ohio
Probes Completed 0 1
Providers Compliant after Round 1 Completion 0 0
Providers Non-compliant after Round 1 Completion 0 1
Providers with Non-Reponses to ADRs for Round 1 0 1

Probe Results

Findings:

  • Components not met for billed level of E/M.
  • E/M billed with Modifier 25 when there was no additional issue addressed on the same date as a procedure with a bundled E/M visit.
  • 2 of 3 E/M components missing from documentation.
  • Monthly visits not medically necessary according to the provided documentation

Strategy: Evaluation and Management Frequency Visits Round 1

Results Kentucky Ohio
Probes Completed 4 2
Providers Compliant after Round 1 Completion 3 1
Providers Non-compliant after Round 1 Completion 1 1
Providers with Non-Reponses to ADRs for Round 1 1 1

Probe Results

Findings:

  • Documentation did not support level of service billed
  • Medical necessity of monthly visits for stable chronic conditions not clear in the documentation
  • No changes to plan of care in response to chief complaint
  • Documentation by a second person not signed with name or credentials
  • Documentation not provided for requested date of service
  • Inappropriate use of Modifier 25

Strategy: Physical & Occupational Therapy Round 1

Results Kentucky Ohio
Probes Completed 0 5
Providers Compliant after Round 1 Completion 0 2
Providers Non-compliant after Round 1 Completion 0 3
Providers with Non-Reponses to ADRs for Round 1 0 0

Probe Results

Findings:

  • No signed physician's order for treatment
  • No certification or recertification signed and dated by physician and physical therapist
  • Duration of timed interventions and total treatment time not provided
  • Daily notes contained no objective measurable statements regarding progress toward at least one goal.

This chart reflects Round 2 probes completed between January 1, 2019 and March 31, 2019

Results Kentucky Ohio
Probes Completed 1 9
Providers Compliant after Round 2 Completion 1 4
Providers Non-compliant after Round 2 Completion 0 5
Providers with Non-Reponses to ADRs for Round 2 1 5

Strategy: Hospital Visits-Round 2

Results Kentucky Ohio
Probes Completed 0 6
Providers Compliant after Round 2 Completion 0 2
Providers Non-compliant after Round 2 Completion 0 4
Providers with Non-Reponses to ADRs for Round 2 0 4

Probe Results

Findings:

  • Documentation does not support split/shared criteria
  • Not meeting elements for level of service billed
  • Documentation not received, or received for the wrong date of service
  • Documentation did not support medical necessity for the visit
  • Lack of GC Modifier use by teaching physicians indicating supervision of student
  • Documentation not signed in a timely manner

Strategy: Laboratory 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 ADRs for Round 2 0 0

Probe Results

Findings:

  • Documentation lacked required elements for service, such as a list of failed medications for GeneSight Refractory Depression testing
  • Physician's signed order for testing received several days after test was completed.
  • Testing not ordered by specialty provider required by Local Coverage Determination L35443.

Strategy: Office Visits-Round 2

Results Kentucky Ohio
Probes Completed 1 2
Providers Compliant after Round 2 Completion 1 1
Providers Non-compliant after Round 2 Completion 0 1
Providers with Non-Reponses to ADRs for Round 2 1 1

Probe Results

Findings:

  • Seen frequently without documentation to support medical necessity
  • Lack of necessary components documented for the billed level of service
  • Minimal updates in documentation from visit to visit
  • Contradictory statements in documentation
  • Visit documentation signed over a week after the date of service
  • Modifier 25 used to bill E/M visit in addition to a procedure without a separately identified problem

Strategy: Office Visits Round 3

Results Kentucky Ohio
Probes Completed 2 0
Providers Compliant after Round 3 Completion 2 0
Providers Non-compliant after Round 3 Completion 0 0
Providers with Non-Reponses to ADRs for Round 3 1 0

Probe Results

Findings:

  • Documentation did not support medical necessity of visit
  • Documentation did not clearly support the frequency of visits, as new, acute issues or high risk status not documented or explained.

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):

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.

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

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