License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

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POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

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May 25, 2023

J15 Targeted Probe Educate Review Status

This article provides the results of Part B Targeted Probe and Educate (TPE) reviews that occurred during the period of September 2022 through February 2023. TPE probe edits were initiated for specific providers identified through data analysis to demonstrate a high risk for improper payment and based on previous probe and targeted reviews. Education was offered to providers throughout and upon completion of each round of the TPE process.

The Medical Review Activity Log includes a complete list of review topics.

CGS Medical Review is dedicated to the integrity of the Medicare program. We welcome provider inquiries and continue to offer education sessions to ensure providers understand CMS regulations with the goal of successful reviews that result in claim payment.

Results for service-specific TPE reviews are listed below.

Drugs/Biologicals Round 1
Results	Kentucky	Ohio
Probes Completed	12	20
Providers Compliant after Round 1 Completion	4	14
Providers Non-compliant after Round 1 Completion	8	6
Providers with Non-Responses to ADRs for Round 1	6	11

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Top Findings

Non-Response – A response to an Additional Documentation Request (ADR) should be submitted within 45 calendar days. If documentation is not submitted, the claim shall deny as not reasonable and necessary. Refer to SSA 1833(e), IOM, Medicare Program Integrity Manual Pub 100-08, Chapter 3, Section 3.3.2
Not Medically Necessary – 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 orders, purchase orders, patient signed consent, and progress notes supporting the medical necessity of the drug/biological administration.

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

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Top Findings

Not Medically Necessary – 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 orders, purchase orders, patient signed consent, and progress notes supporting the medical necessity of the drug/biological administration.

Outpatient Physical and Occupational Therapy Services Round 1
Results	Kentucky	Ohio
Probes Completed	23	14
Providers Compliant after Round 1 Completion	12	4
Providers Non-compliant after Round 1 Completion	11	10
Providers with Non-Responses to ADRs for Round 1	6	5

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Top Findings

Not Medically Necessary – 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.
Non-Response – A response to an Additional Documentation Request (ADR) should be submitted within 45 calendar days. If documentation is not submitted, the claim shall deny as not reasonable and necessary. 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 Round 2
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-Responses to ADRs for Round 1	0	0

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Top Findings

Incomplete/Incorrect Documentation – Refer to: IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15
Therapy Cap Reached – Refer to: Medicare Claims Processing Manual, Chapter 5 - Part B Outpatient Rehabilitation and CORF/OPT Service, Section 10.3.3

Ambulance Services Round 1
Results	Kentucky	Ohio
Probes Completed	0	8
Providers Compliant after Round 1 Completion	0	3
Providers Non-compliant after Round 1 Completion	0	5
Providers with Non-Responses to ADRs for Round 1	0	2

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Top Findings

Not Medically Necessary – The documentation submitted does not support medical necessity. Refer to CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 10 – Ambulance Services.
Reduced Payment – Documentation does not support emergent transport.

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

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Top Findings

Not Medically Necessary – The documentation submitted does not support medical necessity. Refer to CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 10 – Ambulance Services.
Reduced Payment – Documentation does not support emergent transport.

Cataract Removal Services Round 1
Results	Kentucky	Ohio
Probes Completed	7	4
Providers Compliant after Round 1 Completion	5	3
Providers Non-compliant after Round 1 Completion	2	1
Providers with Non-Responses to ADRs for Round 1	1	2

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Top Findings

Not Medically Necessary – The documentation submitted does not support medical necessity. Refer to LCD L33954: Cataract Extraction.
Non-Response – A response to an Additional Documentation Request (ADR) should be submitted within 45 calendar days. If documentation is not submitted, the claim shall deny as not reasonable and necessary. Refer to SSA 1833(e), IOM, Medicare Program Integrity Manual Pub 100-08, Chapter 3, Section 3.3.2.

Importance of Responding to Additional Documentation Requests

During TPE review, CGS identified a high error rate due to non-response to an ADR.

Any claim submitted to CGS is subject to medical review. When a claim is selected for medical review, a medical review additional documentation request (MR ADR) is generated. An MR ADR is a request for you to submit medical documentation 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 (cgsmedicare.com)

Additional Documentation Request Timeliness Calculator

How to Respond to ADRs

You may respond to ADRs via one of these methods:

Mail – Hardcopy or CD/DVD
Fax
myCGS
- Register for myCGS
- Medical Review Dashboard

Resources

You may email inquiries and education requests to: J15BMREDUCATION@cgsadmin.com.

CGS encourages providers to request education and conduct self-monitoring based on our Medical Review activity log and tools such as Comparative Billing Reports (CBRs) offered through the myCGS portal.

To learn more about the TPE process, please reference:

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 Educate Review Status

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