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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:

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.

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:

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