MAC Education and TPE

on Tuesday, 14 November 2017. All News Items | MAC Reviews

Seeking Education

Wednesday@One articles over the past few months have provided information concerning the new medical review strategy for the Medicare Administrative Contractors (MACs) – the Targeted Probe and Educate (TPE) process. Medicare is requiring all MACs to transition to this strategy because it has proven more effective for educating providers and reducing appeals. See last month’s Wednesday@One medical review article for more details on the TPE process. One main element of TPE is one-on-one provider education. MACs will contact individual providers to arrange for education on the review topics after an initial review and after a second review if required.

It could be said the MACs are “spoon feeding” education to providers. The term “spoon feeding” can have negative connotations, implying the recipient is either too lazy or not smart enough to get what is needed by themselves. And in fact, even before the TPE process, many of the MACs had robust information and education concerning the medical review topics on their websites. But having worked in a hospital for many years, I do not think providers are too lazy or too dumb to search out education themselves – they are often simply too busy. In light of this, I agree with Medicare’s plan that targeting education to individual providers based on findings of a targeted review can be an effective process.

One of the goals of Medical Management Plus, Inc. is to educate hospital providers concerning coding, billing and documentation requirements, especially related to Medicare services. We hope our readers gain knowledge from our articles they can apply proactively, that is before a Medicare review. We also routinely point out Medicare sources of information/education, which again can be applied proactively.

The published announcements and findings from MAC medical reviews are a great place to look for education.  For example:

  • WPS J8 results from their HBO with a primary diabetes diagnosis audit. They only looked at 8 claims, but all 8 claims were denied in part or full. The results article gives a list of reasons for the denials, such as lack of documentation of the wound’s Wagner grade, failed wound therapy, and the wound was due to diabetes. See the results article for more details.
  • Palmetto GBA JM has articles under their Medical Review General webpage listing the medical review top denial reasons for different types of providers. Lack of medical necessity was in the top 3 reasons for both inpatient and outpatient Part A reviews for July – September 2017. Also in the top 3 was “requested records not submitted.” Unless this was an error by the MAC, there is no excuse for this type of denial. All hospitals should track their medical review denial reasons and modify necessary processes if records are not being submitted timely in response to Additional Documentation Request (ADRs).
  • NGS JK closed out an audit for skin substitutes which had payment error rates of 45-71%. Missing or incomplete documentation was the main denial reason with missing documentation of progress notes; initial evaluation/progress notes documenting diagnosis with date of onset and all prior treatment modalities, initial size of wound/ulcer(s), wound size at beginning of conservative treatment, progress during conservative treatment and results of any pertinent diagnostic tests or procedures; documentation of previous failed conservative wound care treatment of greater than four weeks in duration; and history and physical examination.

Updates since last month concerning Targeted Probe and Educate are:

  • Cahaba GBA JJ is discontinuing TPE due to the pending JJ transition to Palmetto,
  • Novitas JH and JL posted a start date of December 1, 2017 for TPE review of severe malnutrition,
  • Palmetto JM posted an article about the TPE process with a link to their Active Review Topics, and
  • First Coast does not have a TPE webpage or article yet, but has education on the TPE process scheduled for December 16, 2017.

Even with the TPE process, do not sit back and wait to hear from your MAC – be proactive in seeking education and correcting your processes as needed so you will already be compliant when Medicare does come to review.

Other medical review updates since last month are listed below.

MACService DescriptionService CodeDateError/Denial RateStatus
Novitas JH Severe Malnutrition E41 and E43 12/1/2017   New
Novitas JL Severe Malnutrition E41 and E43 12/1/2017   New
NGS JK Skin Substitute Q4101, Q4102, Q4124, Q4131 10/16/2017 CY15 Q3 - 67.61%
CY15 Q4 - 65.63%
CY16 Q1 - 59.85%
CY16 Q2 - 70.97%
CY16 Q3 - 51.20%
CY16 Q4 - 44.58%
Palmetto Herceptin J9355 9/13/2017   New
WPS J5 HBO Therapy G0277 and 99193 10/23/2017   New
WPS J5 DRG Validation   10/23/2017   New
WPS J5 ER Evaluation and Management (physician) 99281-99285 10/23/2017   New
WPS J5 HBO with primary dx diabetes HCPCS G0277 9/20/2017
WPS J5 High Dollar Claims Interim Results   9/20/2017
WPS J5 OP Diagnostic Procedure-Bone Mass Measurement    9/20/2017
WPS J5 OP Hospital Services - Interim Results - Questionable Covered Services   9/20/2017
WPS J8 HBO Therapy G0277 and 99193 10/23/2017   New
WPS J8 DRG Validation   10/23/2017   New
WPS J8 ER Evaluation and Management (physician) 99281-99285 10/23/2017   New
WPS J8 High Dollar Claims Interim Results   9/20/2017 26% Continue
WPS J8 HBO G0277 with primary diagnosis diabetes 9/20/2017
WPS J8 OP Hospital Services - Interim Results - Questionable Covered Services   9/20/2017
WPS J8 OP Hospital Services - Interim Results - Dental Services   9/20/2017


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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