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February 4, 2020

J15 Targeted Probe and Educate Status Update October 1, 2019 – December 31, 2019

This article is to provide results of Part B Targeted Probe and Educate (TPE) reviews that have occurred during the period of October 1, 2019 through December 31, 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 36 prepay/post pay provider reviews during the above period. 42 probes were completed during this timeframe. 9 providers progressed to Round 2 based on previous TPE review results. 11 providers progressed to Round 3. The chart below lists numbers of completed probes between October 1, 2017-December 31, 2019.

Results	Kentucky	Ohio
Probes Completed	100	131
Providers Compliant after Round 1 Completion	38	42
Providers Non-compliant after Round 1 Completion	59	86
Providers with Non-Responses to ADRs for Round 1	37	42

This chart reflects probes completed between October 1, 2019 and December 31, 2019

Results	Kentucky	Ohio
Probes Completed	16	26
Providers Compliant after Round Completion	7	13
Providers Non-compliant after Round Completion	9	13
Providers with Non-Responses to ADRs	5	9

The results of the Probes per Strategy are listed below:

Strategy: Emergency Room – 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 of Round 3 Probes

Findings

Level of service billed not supported by documentation.

Strategy: Nursing Facility Visits – 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-Responses to ADRs for Round 1	0	0

Results of Round 3 Probes

Findings

Level of service billed not supported by documentation.
Documentation did not support medical necessity of frequent visits

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-Responses to ADRs for Round 1	0	0

Results of Round 3 Probes

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 Visits – Round 1

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

Results of Round 3 Probes

Findings

Documentation did not support the level of service billed.
Documentation did not support medical necessity of visit frequency.
New complaints inappropriately addressed by NPP billing incident to supervising physician

Strategy: Hospital 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	1	0
Providers with Non-Responses to ADRs for Round 1	1	0

Results of Round 3 Probes

Findings

· Documentation submitted was for the incorrect beneficiary

Strategy: Physical & Occupational Therapy – Round 1

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

Results of Round 3 Probes

Findings

Denied claims were rebilled with changes in modifiers and codes.
No PT or MD signature on Evaluation/Plan of Care.
Documentation signed only by PTA with no signature of supervising PT.
Documentation indicates no objective measures of improvement after significant periods of treatment.
Submitted documentation incomplete

Strategy: Psychiatric Services – Round 1

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

Results of Round 3 Probes

Findings

Stable patients seen frequently with no changes or updates
No documentation of Treatment Plan, prognosis, or progress to date
Time spent in sessions not recorded
Level of service billed not supported by documentation.
Billing provider different from performing provider

This chart reflects Round 2 probes completed between October 1, 2019 and December 31, 2019:

Results	Kentucky	Ohio
Probes Completed	4	11
Providers Compliant after Round 2 Completion	1	3
Providers Non-compliant after Round 2 Completion	3	8
Providers with Non-Responses to ADRs for Round 2	0	0

Results of Round 2 Probes per Strategy

Strategy: Ambulance Round 2

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

Results of Round 3 Probes

Findings

PCS illegible or missing from provided documentation
PCS forms for scheduled repetitive transports not signed by patient’s primary care physician, or were not legible.
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.
PCS expired
Submitted documentation not for the requested date of service.

Strategy: Hospital Visits – 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-Responses to ADRs for Round 2	0	0

Results of Round 3 Probes

Findings

Lack of required components for CPT code billed
Date of service billed was not the date the service was provided.

Strategy: Nursing Facility Visits-Round 2

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

Results of Round 3 Probes

Findings

Requested documentation not received.
Documentation did not meet minimal requirements for service level billed
Documentation partially illegible

Strategy: Nursing Home 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-Responses to ADRs for Round 2	0	1

Results of Round 3 Probes

Findings

Documentation did not meet minimal requirements for service level billed

Strategy: Office Visit Frequency – 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-Responses to ADRs for Round 2	0	0

Results of Round 3 Probes

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

Strategy: Physical & Occupational Therapy – Round 2

Results	Kentucky	Ohio
Probes Completed	3	7
Providers Compliant after Round 2 Completion	1	3
Providers Non-compliant after Round 2 Completion	2	4
Providers with Non-Responses to ADRs for Round 2	0	1

Results of Round 3 Probes

Documentation lacked objective measurable progress towards goals
Re-certifications signed after the 30 day limit with no attestation from signing provider
Lack of required signatures
Incomplete documentation submitted

This chart reflects Round 3 probes completed between October 1, 2019 and December 31, 2019:

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

Results of Round 3 Probes per Strategy

Strategy: Hospital Visits – Round 3

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

Results of Round 3 Probes

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
Improper use of Modifier 25 to bill E/M with procedure without another separate issue addressed
Visit billed to wrong provider
No documentation or partial documentation received for requested dates of service
Late documentation
Medical necessity of visit not supported in submitted documentation

Strategy: Nursing Facility 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	1	0

Results of Round 3 Probes

Findings

Illegible documentation received
Documentation did not support the level of service billed.
Documentation did not support the medical necessity of the visit.

How to Prevent Denials:

Documentation did not meet key components of the E/M service billed
- Fact sheets
Ambulance – Both crew members did not sign run sheets with signatures and credentials:
- Ambulance Crew Member Signatures article
Split/Shared not properly documented:
- Split/Shared visits
- § Pub. 100-02, Chapter 15 §§§ 60.1; 60.2; 60.3
- § Pub. 100-04, Chapter 12, §30.6.1B
Medical necessity was not documented appropriately:
- SSA 1862(a)(1)(A)
Nursing facility visits:
Critical Care Evaluation and Management Services:
- PUB. 100-4, CH. 12, §30.6.12.
No documentation was received (non-response):
- SSA 1833(e)
Laboratory:
- LCD: MolDX GeneSight Assay for Refractory Depression
Local Coverage Determination for MolDX: GeneSight ® Assay for Refractory Depression (L35443)

Outpatient Physical and Occupational Services

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.

Comparative Billing Reports (CBRs) are Now Available through myCGS!

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

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")

J15 Targeted Probe and Educate Status Update October 1, 2019 – December 31, 2019

Strategy: Emergency Room – Round 1

Findings

Strategy: Nursing Facility Visits – Round 1

Findings

Strategy: Ambulance – Round 1

Findings

Strategy: Office Visits – Round 1

Findings

Strategy: Hospital Visits – Round 1

Findings

Strategy: Physical & Occupational Therapy – Round 1

Findings

Strategy: Psychiatric Services – Round 1

Findings

Strategy: Ambulance Round 2

Findings

Strategy: Hospital Visits – Round 2

Findings

Strategy: Nursing Facility Visits-Round 2

Findings

Strategy: Nursing Home Visits – Round 2

Findings

Strategy: Office Visit Frequency – Round 2

Findings

Strategy: Physical & Occupational Therapy – Round 2

Strategy: Hospital Visits – Round 3

Findings

Strategy: Nursing Facility Visits – Round 3

Findings

How to Prevent Denials:

Next Steps:

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