Update on Targeted Probe and Educate Program

on Monday, 19 March 2018. All News Items | MAC Reviews

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.

MACTPE TopicTopic 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.

MACService DescriptionService CodeDateStatus
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

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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