March 4, 2024
Targeted Probe and Education Program to Focus on Evaluation and Management (E/M) Services
The CGS Targeted Probe and Education program will begin review of claims associated with E/M services. Guidance for these services may be found in the Internet Only Manual Publications 100-04 and 100-02.
All E/M visit claims must meet all requirements regarding medical reasonableness and necessity as outlined in the applicable statute, regulations, and manual provisions.
We expect the documentation submitted to include a copy of the following legible and signed documentation from each patient's medical record:
- Beneficiary’s name
- Date of service
- Signed Medical Records which establish:
- reason for encounter
- history
- assessment
- past and present diagnoses
- prior diagnostic test results
- Any other documentation supporting medical necessity
- Copy of any mandatory ABNs
- Appropriate signatures
- Signature and credentials of person performing the service must meet CMS requirements
- Amendments/corrections/delayed entries are properly identified
For additional documentation requirements, please reference:
MLN Evaluation Management Service Guide https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf
CMS Medicare Program Integrity Manual (Pub. 100-08), Chapter 3, Section 3.3.2.4
Definition of "Medically Necessary": Social Security Act (SSA), Section 1862 (a)(1)(A)
Medicare Benefit Policy Manual 100-02 | CMS
Medicare Claims Processing Manual 100-04 | CMS
CPT codes under review will include:
- 99202-99205 (New Patient)
- 99211-99215 (Subsequent)
For more information on Targeted Probe and Education, please see the following links:
- CGS Targeted Probe & Educate Webpage
- Targeted Probe and Educate (TPE) Process
- Targeted Probe and Educate FAQs
- Centers for Medicare & Medicaid Services (CMS) TPE Webpage
Consider using the myCGS Portal for claim review status and submission of documentation. For more information, please access myCGS