INTRODUCTION

The Targeted Probe and Educate (TPE) Process is designed to help providers and suppliers reduce claims denials and appeals through one-on-one help. The TPE goal is to help providers quickly improve. Medicare Administrative Contractors (MACs) work with the providers, in person, to identify errors and assist with correction. Many common errors are simple- such as a missing physician's signature- and are easily corrected.[1] The Targeted Probe and Educate should not be a concern for most providers. The majority that have participated in TPE process increased the accuracy of their claims. 

This topic describes the Centers for Medicare and Medicaid (CMS) Targeted Probe and Educate Process in a lean protocol format. For definition, selection criteria and video explaining the process, see blog post "CMS Targeted Probe and Educate for HBOT Codes 99183 & G0277". For a Medicare billing workflow and protocol including an interactive process map see topic "Medicare Billing Protocol and Workflow". And for a protocol on claims appeal see topic "Medicare Billing Protocol - Appeal of Claim". 

PROTOCOL

A protocol for Medicare Targeted Probe and Educate in wound care and hyperbaric clinics is provided

Process: Notification of selection for Targeted Probe and Educate Process

Process: Round 1 of Targeted Probe and Educate

Process: Round 2 of Targeted Probe and Educate

Process: Round 3 of Targeted Probe and Educate

ADDITIONAL DOCUMENTATION REQUEST (ADR)

The Initial Notification Letter from most MACs includes a documentation checklist to help providers prepare documentation for submission. Documentation checklists can also be found on each MAC's website under Medical Review, Targeted Probe and Educate. The Additional Documentation Request (ADR) should also list the required documentation. Not responding to the request counts as an error and may place the provider in the next round of TPE, expediting the TPE process.

It is imperative that when responding to the TPE ADRs providers include the name and number of the designated contact person for the facility. Most MACs will contact that designated person prior to the conclusion of each TPE round to discuss the review summary. 

Medicare may request the following documentation:

• Documentation to support the dates of service billed may include, but is not limited to:
• HBO treatment records
• Signed order for HBO services
• Documentation to support medical necessity may include, but is not limited to:
• Documentation to support services are for treating a condition as described in CMS Pub 100-03, Medicare National Coverage Determination (NCD) Manual, Chapter 1, Coverage Determination, 20.29, Hyperbaric Oxygen Therapy (HBOT) [2]   
• History and physical that clearly describes the condition for which hyperbaric oxygen therapy is recommended
• Physician progress note(s) that support all adjunctive therapies provided to the beneficiary in the treatment of the diagnosed condition
• Laboratory and pathology report(s) if applicable
• Documentation to support minimum (30) days of failed conservative treatment(s) of wound with wound measurements and photographs if applicable
• Operative and/or procedure reports related to the diagnosis if applicable
• Date and anatomic site of radiation treatment if applicable
• Prior antibiotic administration record to support chronic condition if applicable (i.e. chronic osteomyelitis)
• Hyperbaric oxygen therapy procedure log(s) to include decent time, ascent time and pressurization level
• Direct physician supervision
• Assessment of condition minimum (30) days during HBOT
• For a condition where HBOT is covered where there is a threatened loss of function, limb or life, the documentation must support the condition 
• Advanced Beneficiary Notice (if applicable)[1] 

For additional guidance provided by each MAC on how to prepare and respond to ADRs, see Table 1 below. To see MACs' jurisdictions in the United States, see topic "Medicare Coverage Determinations for Hyperbaric Oxygen Therapy" 

Table 1. Additional guidance provided by each MAC on how to prepare and respond to ADRs  

Many HBO services failed the first round of the program because they did not submit the correct documentation, or they ignored the request and did not submit any documentation.[11] Listed below is a summary of the most recent findings. 

WPS: March 2019 - Round one TPE findings

WPS GHA J5A Targeted Probe & Education (TPE) 5PEF1 

Through complex data analysis, WPS GHA Medical Review Part A identified providers with billing practices significantly different as compared to other providers in the community. The HBOT providers selected for TPE received education prior to, during, and after the probe process. Each probe evaluated 20-40 claims. The results of J5A Hyperbaric Oxygen Therapy 5PEF1 TPE Round One are as follows: 

Findings

• 17 probes completed
• 7 providers released after Round One completion
• 10 providers moving to Round Two for additional review
• The average error rate of providers moving to Round Two is 42.6%

MOST COMMON REASONS FOR DENIAL

• There is no documentation of initial and repeated wound measurements during 30 days of conservative treatment for diabetic wound management
• Documentation must support one of the covered conditions by Local Coverage Determination (LCD) or an Article (LCA) for medical review based on the National Coverage Determination (NCD) for Hyperbaric Oxygen (HBO) therapy.
  
• Insufficient documentation of failed standard treatment or debridement of diabetic wounds

Novitas: Start Date: 4/1/2018 - Round one TPE findings

Novitas GHA J5A Targeted Probe & Education (TPE) 5PEF1 

Through complex data analysis, Medical Review Part A identified provider billing practices and services that pose the greatest financial risk to the Medicare program. Providers chosen to participate in Hyperbaric Oxygen Therapy (HBO) Targeted Probe and Educate (TPE) through the Data Analysis process were offered education prior to, during, and after the probe process had been completed. The results of JH Hyperbaric oxygen therapy (HBO) 5HH11 TPE Round 1 are as follows [12]: 

FINDINGS

• 38 probes completed
• 23 probes closed with a minor error classification
• 6 probes closed with a moderate error classification
• 3 probes closed with a major error classification
• 6 probes closed with an insufficient sample size

Most common reasons for denial

The most common reasons for denial were:

• Insufficient documentation to support services medically reasonable and necessary
• Incomplete or missing treatment records
• Insufficient documentation of diagnostic or physician progress note to confirm diagnosis
• Missing signed physician’s order for treatment
• Insufficient documentation of response to treatment or measurable signs of healing
• Insufficient documentation of failed standard treatment or debridement of diabetic wounds

Common Denial Codes

The Table 2 below shows common denial codes from published TPE audits reports so far. For all denial codes, See Topic  CMS HBO Non-Emergent Denial Reason Codes and Statements.

Table 2. Common denial codes from published TPE audits

TPE FINDINGS - WOUND CARE

Medicare's Targeted Probe and Educate extends beyond HBOT and into the wound care arena. In fact, providers in the WPS J5 area (Nebraska, Iowa, Kansas and Missouri) are receiving notifications for targeted probe and educate for debridement services and application of cellular and/or tissue products. WPS has provided a Wound Care Checklist to assist with a successful review of the documentation. 

REVISION UPDATES