Update on Targeted Probe and Educate Program
Learning from the Mistakes of Others
Since last month’s Medical Review article, two more Medicare Administrative Contractors (MACs) have posted Targeted Probe and Educate (TPE) medical review issues. As a reminder, CMS expanded the TPE medical review strategy to all MAC reviews effective October 1, 2017. This does not mean MAC TPE reviews actually began on this date. It has taken time for the MACs to wrap up and discontinue the active reviews in process at that time and to select topics and providers for the TPE program. Under the TPE program, MACs use data analysis to target specific providers and topics instead of conducting probe reviews and service-specific reviews of all providers. When topics and selected providers are chosen, there are up to three rounds of reviews of 20-40 records with provider-specific education after a round of reviews is completed. This allows providers to understand the exact deficiencies that caused claim denials so they can take appropriate corrective actions. The need for a second and third round of reviews after the initial and second round respectively is determined based on the review error rates. Further reviews stop when error rates are below an acceptable threshold as determined by the MAC. Providers with a continued moderate or major error classification after three rounds of prepayment TPE reviews will be referred to CMS for possible further action. CMS believes the focused education of the TPE program will be more effective than previous probe and service-specific reviews in reducing and preventing improper payments. The design of the program should also reduce appeals, decrease provider burden, and improve the medical review and education process.
MMP, Inc. provides updates of medical review activity in this newsletter monthly, but since we are approaching the six-month mark of the TPE program, it is a good time to summarize each MACs progress on the TPE process. All MACs have a webpage describing the TPE program and most (if not all) prior reviews have been completed and/or discontinued. Eight (8) of the 12 MACs have published topics for review under the TPE program, CGS and First Coast just this month. Below are the TPE review topics by MAC relevant to Part A short term acute-care hospitals.
|MAC||TPE Topic||Topic Codes|
|CGS J15||Cardiac Rehab with continuous ECG Monitoring||HCPCS 93798|
|CGS J15||Cataract Removal||HCPCS 66984, 66983, 66982|
|CGS J15||Spinal Injections||HCPCS 62323|
|First Coast JN||Outpatient Rehab: OT||Rev Code 043|
|First Coast JN||Outpatient Rehab: PT||Rev Code 042|
|First Coast JN||Outpatient Rehab: SLP||Rev Code 044|
|First Coast JN||Psychoses||DRG 885|
|Novitas JH and JL||Denosumab||HCPCS J0897|
|Novitas JH and JL||Imiglucerace||HCPCS J1786|
|Novitas JH and JL||Ipiliumumab||HCPCS J9228|
|Novitas JH and JL||Kwashiorkor/Marasmic Kwashiorkor > 3 day LOS||ICD-10 E40/E42|
|Novitas JH and JL||Severe Malnutrition||ICD-10 E41 and E43|
|Novitas JH and JL||Sipuleucel T||HCPCS Q2043|
|Palmetto JJ and JM||Major Joint Replacement or Reattachment of Lower Extremity without Major Complication or Comorbidity (MCC)||DRG 470|
|Palmetto JJ and JM||Pegfilgrastim, 6mg||HCPCS J2505|
|Palmetto JJ and JM||Psychoses||DRG 885|
|Palmetto JM||Bevacizumab, 10mg||HCPCS J9035|
|Palmetto JM||Denosumab||HCPCS J0897|
|Palmetto JM||Hyperbaric Oxygen Therapy (HBO)||HCPCS G0277|
|Palmetto JM||Infliximab, 10mg||HCPCS J1745|
|Palmetto JM||Rituximab, 100mg||HCPCS J9310|
|WPS J5and J8||DRG Validation|
|WPS J5and J8||ER Evaluation and Management||CPT 99281-99285|
|WPS J5and J8||HBO Therapy||HCPCS G0277 and CPT 99193|
For the most part, MACs representing two jurisdictions review the same issues in both. Palmetto’s Jurisdiction J is an exception, but this may be due to the fact it only recently transitioned to Palmetto from its prior MAC. As you can see, there are a variety of issues across MACs with only three issues that have been selected for review by more than one contractor – namely Denosumab, HBO therapy, and MS-DRG 885 for Psychoses.
So far, the only results that have been published from TPE reviews are the Novitas JH and JL Round One results of an End Stage Renal Disease (ESRD) review of ESRD facilities. Continue to read this newsletter and view the MACs’ websites to see future results of TPE reviews as well as new topic announcements. Medical review results can be educational for all providers, not just the targeted hospital. It is a good way to learn from the mistakes of others before you have to suffer the consequences of learning from your own errors.
Here are the specific medical review updates that have occurred since last month’s medical review newsletter.
|MAC||Service Description||Service Code||Date||Status|
|Palmetto JM||Denosumab||HCPCS J0897||3/1/2018||Active (new)|
|Novitas JH and JL||Kwashiorkor/Marasmic Kwashiorkor > 3 day LOS||ICD-10 E40/E42||2/28/2018||Active|
|First Coast JN||Psychoses||MS-DRG 885||3/8/2018||New|
|First Coast JN||Outpatient Rehab: PT||Rev Code 042||3/8/2018||New|
|First Coast JN||Outpatient Rehab: OT||Rev Code 043||3/8/2018||New|
|First Coast JN||Outpatient Rehab: SLP||Rev Code 044||3/8/2018||New|
|CGS J15||Cataract Removal||HCPCS 66984, 66983, 66982||Feb-18||New|
|CGS J15||Review for Spinal Injections||HCPCS 62323||Feb-18||New|
|CGS J15||Cardiac Rehab with continuous ECG Monitoring||HCPCS 93798||Feb-18||New|
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.