Education on Targeted Probe and Educate

on Tuesday, 20 February 2018. All News Items | MAC Reviews

Understanding the Process

As the Targeted Probe and Educate (TPE) medical review program kicks into full gear, Medicare Administrative Contractors (MACs) are publishing final results of prior service specific targeted reviews before discontinuing them, announcing current active TPE topics, and providing education on the TPE process itself. See the table at the end of this article for this month’s details of new, discontinued and active issues. Active issues were previously targeted reviews that are moving over to become issues under TPE.

Recently, Palmetto GBA held a teleconference for Jurisdiction J providers on the Targeted Probe and Educate process. Here are some of the key points from the teleconference. Some information may be general and apply to TPE as carried out by all MACs. Other information is specific to Palmetto and will only apply to the providers in Jurisdictions J and M. Providers in other Jurisdictions should check with your area MAC for clarification as needed.

  • Palmetto stressed repeatedly the importance of providing the name and phone number of a contact person at your facility when you submit your medical records in response to an additional documentation request (ADR). They suggest listing this information in the cover letter. Palmetto reviewers may reach out during the inter-probe process to your contact person if:
    • A piece of documentation is missing that is easily curable,
    • A recurring issue is noted that would prevent future denials if corrected now.
  • Review topics are selected based on data analysis of claims payments. Palmetto may also consider CERT error rates, OIG reports, and comparative billing reports (CBRs) to select topics. Providers to be reviewed are selected “based on analysis of the billing data indicating any areas that suggest questionable billing practices or on targeted review and is transitioned to the TPE process based on error rate results.”
  • MACs have 30 days to complete a review once records are received. Palmetto is currently meeting (actually exceeding) this timeframe. Denial letters are sent to the provider describing what was found and education on how to prevent future errors. If there were no errors on the claims, you will see that the claim has moved on for payment in the Direct Data Entry System (DDE). Once the 20-40 claim review is complete, Palmetto will reach out to schedule education with the provider.
  • Palmetto is currently using a threshold of 20% to release providers from the TPE process. Some other MACs have published a threshold of 15%. There is a charge denial rate and a claim denial rate calculated and generally, if either is above the threshold, the review is likely to continue. Rates are based only on the sample reviewed – such as total charges versus total denied charges. Palmetto also considers factors other than the threshold percentage in continuing a review – such as the number of certain types of denials.
  • A list of the current active TPE review topics can be found on Palmetto’s website. They will also be publishing trending, common denial findings and how to avoid denials. Palmetto provides granular findings to the provider explaining the specific reason the claim was denied. (Even before TPE, Palmetto published granular findings on their website related to reviews. I personally found this to be some of the best education provided by any of the MACs, so this should be extremely beneficial to providers in correcting errors.)
  • Initial TPE letters are sent to the address identified by the provider on the 855 provider enrollment to have correspondence mailed. Palmetto has changed the greeting in the letter to be the provider or the compliance officer to help with routing. 
  • Most claims are reviewed on a pre-pay basis. The initial round of post-pay reviews may go back 12-months. Subsequent rounds will be from the education date forward.
  • Appeal outcomes are considered in the error calculations. Palmetto also using appeal outcomes to educate internal staff “to help strengthen our reviews and strengthen our ability to provide appropriate information back to the provider community.”

Palmetto posted the transcript of the teleconference on their website. Check the website of other MACs for information about TPE in their jurisdiction. Most MACs also have a list of active TPE review topics.  Also check out CMS’s webpage on TPE.

This table summarizes MAC medical review activity since last month.

MACService DescriptionService CodeDateError/Denial RateStatus
Palmetto JJ Pegfilgrastim HCPCS J2505 2/5/2018   New
Palmetto JJ Psychoses DRG 885 2/5/2018   New
Palmetto JJ Major Joint Replacement or Reattachment of Lower Extremity without Major Complication or Comorbidity (MCC) DRG 470 2/5/2018   New
Palmetto JM Infliximab, 10mg HCPCS J1745 2/5/2018   New
Palmetto JM Bevacizumab, 10mg HCPCS J9035 2/5/2018   New
Palmetto JM Rituximab, 100mg HCPCS J9310 2/5/2018   New
Novitas JL and JH Imiglucerace J1786 2/7/2018   Active
Novitas JL and JH Ipiliumumab J9228 2/7/2018   Active
Novitas JL and JH Sipuleucel T Q2043 2/7/2018   Active
NGS JK MRI, Brain HCPCS 70551, 70553 1/19/2018 14.21% Discontinued
NGS JK Atherosclerosis DRG 302-303 1/19/2018 7.29% Discontinued
NGS JK Urine Drug Testing HCPCS G0480-G0483 1/19/2018 32.93% Discontinued
NGS JK Respiratory Failure ICD-10 codes: J96.00, J96.01, J96.02, J96.20, J96.21, J96.22 1/19/2018 16.78% Discontinued
NGS JK Group Psychotherapy CPT 90853 1/19/2018 17 Q2 - 61.77%
17 Q3 - 61.75%
NGS JK Individual Psychotherapy CPT 90832 1/19/2018 17 Q1 - 54.12% 17 Q2 - 50.51% 17 Q3 - 42.63% Discontinued
NGS JK Cognitive Skills CPT 97032
(HCPCS G0515-2018)
1/19/2018 17 Q2 - 56.57%
17 Q3 - 72.22%
NGS JK PT Re-evaluation CPT 97002, 97164 1/19/2018 17 Q1 - 55.76% 17 Q2 - 0% 17 Q3 - 72.22% Discontinued
WPS J5 and J8 HBO Therapy G0277 and 99193 1/31/2018   Active
WPS J5 and J8 DRG Validation   1/31/2018   Active



Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc.  Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system.  In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers.  You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information.  MMP, Inc. is not offering legal advice.  Every reasonable effort has been taken to ensure the information is accurate and useful.


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