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August 29, 2019

J15 Targeted Probe and Educate Status Update: April 1, 2019 – June 30, 2019

This article is to provide results of Part B Targeted Probe and Educate (TPE) reviews that have occurred during the period of April 1, 2019 through June 30, 2019. 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 25 prepay/postpay provider reviews during the above period. Nineteen probes were completed during this timeframe. Forty-four providers progressed to Round 2 based on previous TPE review results. Four providers progressed to Round 3. The chart below lists numbers of completed probes between October 1, 2017-June 30, 2019.

Results Kentucky Ohio
Probes Completed 61 83
Providers Compliant after Round 1 Completion 20 19
Providers Non-compliant after Round 1 Completion 38 61
Providers with Non-Responses to ADRs for Round 1 24 24

This chart reflects probes completed between April 1, 2019 and June 30, 2019

Results Kentucky Ohio
Probes Completed 24 37
Providers Compliant after Round Completion 7 6
Providers Non-compliant after Round Completion 17 31
Providers with Non-Responses to ADRs 8 8

The results of the Probes per Strategy are listed below:

Strategy: Nursing Facility Visits – Round 1

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

Findings:

  • No documentation received for one requested claim.

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-Responses to ADRs for Round 1 0 1
results chart

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 Visit Frequency – Round 1

Results Kentucky Ohio
Probes Completed 4 3
Providers Compliant after Round 1 Completion 0 0
Providers Non-compliant after Round 1 Completion 4 3
Providers with Non-Responses to ADRs for Round 1 1 1
results chart

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
  • Risk level to warrant frequent labs not documented.
  • Progress notes lack documentation of intent to order labs
  • No documentation submitted in response to ADR requests

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 not provided for requested date of service
  • Inappropriate use of Modifier 25

Strategy: Physical & Occupational Therapy – Round 1

Results Kentucky Ohio
Probes Completed 11 25
Providers Compliant after Round 1 Completion 0 0
Providers Non-compliant after Round 1 Completion 11 25
Providers with Non-Responses to ADRs for Round 1 3 5
results chart

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.
  • Log sheets contained initials, but no record of signatures and credentials

This chart reflects Round 2 probes completed between April 1, 2019 and June 30, 2019:

Results Kentucky Ohio
Probes Completed 5 7
Providers Compliant after Round 2 Completion 5 7
Providers Non-compliant after Round 2 Completion 2 2
Providers with Non-Responses to ADRs for Round 2 3 1

Results of Round 2 Probes per Strategy

Strategy: Ambulance Round 2

Results Kentucky Ohio
Probes Completed 1 4
Providers Compliant after Round 2 Completion 1 2
Providers Non-compliant after Round 2 Completion 0 2
Providers with Non-Responses to ADRs for Round 2 0 0
results chart

Findings:

  • PCS forms for scheduled repetitive transports not signed by patient's primary care physician.
  • Purpose for transport from one hospital to another not supported in documentation as medically necessary.
  • Run sheet documentation did not support why patient was unable to be transported by other means.

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 ADRs for Round 2 1 0
results chart

Findings:

  • Documentation did not support the level of service billed.

Strategy: Hospital Visits-Round 2

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

Findings:

  • Lack of required components for CPT code billed
  • Lack of necessary documentation for split/shared visit
  • Documentation not received, or received for the wrong date of service
  • Documentation did not support medical necessity for the visit

Strategy: Nursing Facility & Nursing Home Visits-Round 2

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

Findings:

  • Only partial documentation received for review
  • Lack of required components for CPT code billed

Strategy: Office Visits-Round 2

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

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

Results of Round 3 Probes per Strategy

Strategy: Hospital Visits – Round 3

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

Findings:

  • Split/shared visit did not support significant face-to-face interaction between physician and patient.

Strategy: Nursing Facility Visits – Round 3

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

Findings:

  • Lack of necessary components documented for the billed level of service

Strategy: Office Visits – Round 3

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

Findings:

  • Documentation did not support significant separately identifiable evaluation by the same provider on the date of a procedure. Modifier 25 used incorrectly.

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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