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November 25, 2019

J15 Targeted Probe and Educate Status Update July 1, 2019- September 30, 2019

This article is to provide results of Part B Targeted Probe and Educate (TPE) reviews that have occurred during the period of July 1, 2019 through September 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 94 prepay/post pay provider reviews during the above period.  45 probes were completed during this timeframe. 15 providers progressed to Round 2 based on previous TPE review results. 8 providers progressed to Round 3. The chart below lists numbers of completed probes between October 1, 2017-September30, 2019.

Results

Kentucky

Ohio

Probes Completed

84

105

Providers Compliant after Round 1 Completion

31

29

Providers Non-compliant after Round 1 Completion

50

73

Providers with Non-Reponses to ADR’s for Round 1

32

33

This chart reflects probes completed between July 1, 2019 and September 30, 2019

Results

Kentucky

Ohio

Probes Completed

23

22

Providers Compliant after Round Completion

11

10

Providers Non-compliant after Round Completion

12

12

Providers with Non-Reponses to ADR’s

8

9

 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

0

0

Providers Non-compliant after Round 1 Completion

1

0

Providers with Non-Reponses to ADR’s for Round 1

0

0

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Findings:

  • Level of service billed not supported by documentation.
  • Place of Service 02 not used for telehealth services.

Strategy: Ambulance – Round 1

Results

Kentucky

Ohio

Probes Completed

2

 0

Providers Compliant after Round 1 Completion

0

 0

Providers Non-compliant after Round 1 Completion

2

 0

Providers with Non-Reponses to ADR’s for Round 1

0

 0

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Findings:

  • Medical necessity for ambulance transport not established
  • PCS Forms not provided or signed by persons other than primary care physician for scheduled repetitive transports.
  • Both crew members not adding their signature and credentials to the run documentation.

Strategy: Office Visit Frequency – Round 1

Results

Kentucky

Ohio

Probes Completed

7

0

Providers Compliant after Round 1 Completion

2

0

Providers Non-compliant after Round 1 Completion

5

0

Providers with Non-Reponses to ADR’s for Round 1

3

0

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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 and office visits not documented.
  • Progress notes lack documentation of intent to order labs

Strategy: Office Visits – Round 1

Results

Kentucky

Ohio

Probes Completed

1

Providers Compliant after Round 1 Completion

0

Providers Non-compliant after Round 1 Completion

1

Providers with Non-Reponses to ADR’s for Round 1

0

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Findings:

  • Telehealth visits billed without Place of Service Code 02, to indicate compliance with site and equipment requirements

Strategy: Hospital Visits – Round 1

Results

Kentucky

Ohio

Probes Completed

 0 

2

Providers Compliant after Round 1 Completion

 0

1

Providers Non-compliant after Round 1 Completion

 0

1

Providers with Non-Reponses to ADR’s for Round 1

 0

1

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Findings:

  • Documentation did not support level of service billed
  • Medical necessity of continued hospital care not clear in the documentation
  • Requested documentation not received

Strategy: Physical & Occupational Therapy – Round 1

Results

Kentucky

Ohio

Probes Completed

3

6

Providers Compliant after Round 1 Completion

0

0

Providers Non-compliant after Round 1 Completion

3

6

Providers with Non-Reponses to ADR’s for Round 1

2

4

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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.
  • Physical Therapy Assistants provided care on the date of an evaluation, but documentation was not clear what services they performed.

Strategy: Psychiatric Services – Round 1

Results

Kentucky

Ohio

Probes Completed

1

1

Providers Compliant after Round 1 Completion

1

0

Providers Non-compliant after Round 1 Completion

0

1

Providers with Non-Reponses to ADR’s for Round 1

0

0

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Findings:

  • Stable patients seen frequently with no changes or updates
  • No documentation of Treatment Plan or prognosis
  • Time spent in sessions not recorded

This chart reflects Round 2 probes completed between July 1, 2019 and September 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-Reponses to ADR’s for Round 2

3

1

Results of Round 2 Probes per Strategy

Strategy: Ambulance Round 2

Results

Kentucky

Ohio

Probes Completed

1

2

Providers Compliant after Round 2 Completion

1

12

Providers Non-compliant after Round 2 Completion

0

1

Providers with Non-Reponses to ADR’s for Round 2

0

1

Screen Shot

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: Critical Care - Round 2

Results

Kentucky

Ohio

Probes Completed

0

1

Providers Compliant after Round 2 Completion

0

0

Providers Non-compliant after Round 2 Completion

0

1

Providers with Non-Reponses to ADR’s for Round 2

0

1

Screen Shot

Findings:

  • Documentation did not support the level of service billed.

 Strategy: Hospital Visits - Round 2

Results

Kentucky

Ohio

Probes Completed

2

1

Providers Compliant after Round 2 Completion

2

1

Providers Non-compliant after Round 2 Completion

0

0

Providers with Non-Reponses to ADR’s for Round 2

1

0

Screen Shot

Findings:

  • Lack of required components for CPT code billed
  • Documentation not received, or received for the wrong date of service

Strategy: Nursing Facility Visits-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:

  • Documentation does not support CPT code billed.

Strategy: Office Visits-Round 2 

Results

Kentucky

Ohio

Probes Completed

1

2

Providers Compliant after Round 2 Completion

0

1

Providers Non-compliant after Round 2 Completion

1

1

Providers with Non-Reponses to ADR’s for Round 2

1

2

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Findings:

  • Seen frequently without documentation to support medical necessity
  • Modifier 25 used incorrectly with no separately identifiable E/M service not covered by a procedure
  • Lack of necessary components documented for the billed level of service
  • Claims allowed 100% on Round 2.

Strategy: Physical & Occupational Therapy – 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

Results of Round 3 Probes per Strategy

Home Visits – Round 3 

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-Reponses to ADR’s for Round 2

1

 0

Screen Shot

Findings:

  • Requested documentation not received

Strategy: Hospital Visits – Round 3

Results

Kentucky

Ohio

Probes Completed

3

Providers Compliant after Round 3 Completion

3

Providers Non-compliant after Round 3 Completion

0

Providers with Non-Reponses to ADR’s for Round 3

0

Screen Shot

Findings:

  • Split/shared visit did not support significant face-to-face interaction between physician and patient.
  • Documentation did not support the level of service billed
  • Requested documentation not received
  • Documentation received for the wrong dates of service
  • No documentation or partial documentation received for requested dates of service

Strategy: Office Visits – Round 3

Results

Kentucky

Ohio

Probes Completed

1

1

Providers Compliant after Round 3 Completion

1

1

Providers Non-compliant after Round 3 Completion

0

0

Providers with Non-Reponses to ADR’s for Round 3

0

0

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Findings:

  • Documentation did not support significant separately identifiable evaluation by the same provider on the date of a procedure. Modifier 25 used incorrectly.
  • Incomplete documentation received
  • Documentation did not meet the level of service billed.

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)PDF offered through our web portal.

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

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