December 2, 2022
J15 Targeted Probe Educate Review Status
The Centers for Medicare & Medicaid Services (CMS) resumed the Targeted Probe & Educate (TPE) process on September 1, 2021. Based on data analysis of claims payment, CGS will identify areas with the greatest risk of inappropriate program payment. You may reference the Medical Review Activity Log for a list of review topics.
CGS Medical Review is dedicated to the integrity of the Medicare program. CGS welcomes provider inquiries and continues to offer education sessions to ensure providers understand CMS regulations with the goal of successful reviews resulting in claim payment.
Results for service specific TPE reviews are listed below.
Drugs/Biologicals
Results | Ohio |
---|---|
Probes Completed | 2 |
Providers Compliant after Round 1 Completion | 1 |
Providers Non-compliant after Round 1 Completion | 1 |
Providers with Non-Responses to ADRs for Round 1 | 1 |
Top Findings:
- Non-Response - ADR response should be submitted within 45 calendar days. Claims shall deny as not reasonable and necessary if documentation is not submitted. Refer to SSA 1833(e), IOM, Medicare Program Integrity Manual Pub 100-08, Chapter 3, Section 3.3.2
Outpatient Physical and Occupational Therapy Services - 97110
Results | Kentucky | Ohio |
---|---|---|
Probes Completed | 12 | 8 |
Providers Compliant after Round 1 Completion | 7 | 3 |
Providers Non-compliant after Round 1 Completion | 5 | 5 |
Providers with Non-Responses to ADRs for Round 1 | 2 | 2 |
Top Findings:
- The documentation submitted does not support medical necessity. Refer to SSA 1862, IOM, Medicare Program Integrity Manual, Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2.
The submitted documentation lacked elements such as physician order, signed certification/recertification, progress notes, and documentation supporting the medical necessity of visits exceeding recommended amount.
- Therapy Cap Reached. Refer to CMS Medicare Claims Processing Manual Chapter 5 Section 10.3
Psychiatry Services
Results | Ohio |
Probes Completed | 4 |
Providers Compliant after Round 1 Completion | 4 |
Providers Non-compliant after Round 1 Completion | 0 |
Providers with Non-Responses to ADRs for Round 1 | 2 |
Top Findings:
- The documentation submitted does not support medical necessity. Refer to SSA 1862, IOM, Medicare Program Integrity Manual, Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2.
- Non Response- ADR response should be submitted within 45 calendar days. Claims shall deny as not reasonable and necessary if documentation is not submitted. Refer to SSA 1833(e), IOM, Medicare Program Integrity Manual Pub 100-08, Chapter 3, Section 3.3.2
Ambulance Services
Results | Kentucky | Ohio |
Probes Completed | 7 | 15 |
Providers Compliant after Round 1 Completion | 4 | 8 |
Providers Non-compliant after Round 1 Completion | 3 | 7 |
Providers with Non-Responses to ADRs for Round 1 | 0 | 4 |
Top Findings:
- The documentation submitted does not support medical necessity. Refer to CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 10, Ambulance Services
- Non Response- ADR response should be submitted within 45 calendar days. Claims shall deny as not reasonable and necessary if documentation is not submitted. Refer to SSA 1833(e), IOM, Medicare Program Integrity Manual Pub 100-08, Chapter 3, Section 3.3.2
Importance of responding to Additional Request Documentation:
During TPE review, there has been a high error rate due to non-response to the ADR.
Any claim submitted to CGS may be selected for medical review and generate an MR ADR. When a claim is selected for medical review, a medical review additional development request (MR ADR) is generated requesting medical documentation be submitted to ensure payment is appropriate
Contractors are authorized to collect medical documentation by the Social Security Act. Section 1833(e) states, "No payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period."
Section 1815(a) states "…no such payments shall be made to any provider unless it has furnished such information as the Secretary may request in order to determine the amounts due such provider under this part for the period with respect to which the amounts are being paid or any prior period."
Additional Documentation Requests (ADRs): How and What to Send
New Additional Development Request Timeliness Calculator Self-Service Option
Methods of Responding to ADRs:
ADRs may be submitted via
- Mail: Hardcopy or CD/DVD
- Fax
- myCGS (Free web portal, will accept response to ADRs)
Resources:
- Ambulance Fact Sheet
- HCPCS J0129 Fact Sheet
- HCPCS J0178 Fact Sheet
- HCPCS J2507 Fact Sheet
- Outpatient Physical and Occupational Therapy Services (LCD L34049) Fact Sheet
- Outpatient Psychiatry & Psychology (LCD L34353) Fact Sheet
- Signature Tips
- CGS Part B MR Activities
Provider inquiries and education requests may be email to J15BMREDUCATION@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.
To learn more about the post payment resumptive process, please refer to the following links: