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Medicare Targeted Probe and Educate Protocol

Medicare Targeted Probe and Educate Protocol

Medicare Targeted Probe and Educate Protocol

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

Important tasksKey points (how to execute the task)Reason (why execute this task?)
The provider or Facility receives a letter from the MAC informing of a Targeted Probe and Educate Process
  • Follow instructions of letter
  • Do not send any documentation at this time
  • The claims processing center will notify you of the Additional Documentation Request (ADR) that will be sent for the claims selected for review.
  • ADR will include a list of suggested documentation needed to support the service in review
  • Ensure there is a process for routing the ADR to the wound and HBO Clinic 
  • The MAC will most likely send the TPE request to the hospital billing department. Inform the hospital billing department that if they should receive this notice, it should immediately be forwarded to the wound clinic/ HBO nurse manager

MACs use data analysis to identify:

  • Providers and suppliers who have high claim error rates or unusual billing practices
  • Items and services that have high national error rates and are a financial risk to Medicare.
  • Communication inter-departmentally will ensure the hyperbaric unit is given time to prepare and respond to the TPE
Additional Documentation Request (ADR). Issued by MAC and received by hospital
  • Hospital billing department forward to wound/ HBO clinic nurse manager
  • Return requested documentation within 45 days
  • After all claims selected for the probe are reviewed by the MAC, the provider will receive a letter of specific findings of the review
  • If requested ADR documentation is not received by the MAC within 45 days, the claims will be denied due to lack of documentation which will contribute to your error rate.  
  • If providers do not respond to the ADR request, MAC’s have the option to refer to the Recovery Audit Contractor (RAC) or Zone Program Integrity Contractors (ZPIC)/ Unified Program Integrity Contractor (UPIC).
  • Not responding to the request counts as an error and may place the provider in the next round of TPE, expediting the process 

Process: Round 1 of Targeted Probe and Educate

Important tasks
Key points (how to execute the task)
Reason (why execute this task?)
Medicare selects providers for targeted review based on data analysis 

If selected:

  • Probe: Medicare reviews 20-40 claims per provider/facility
The purpose of the claim review is to ensure documentation supports the reasonable and necessary criteria of the services billed and follows Medicare rules and regulations
If Medicare finds the claims to be compliant, Probe is discontinued for 12 months or more
  • Continue with adequate documentation
You may be released from further review after any round if your documentation shows the required improvement
If Medicare finds the claims to be non-compliant, then "Educate" may occur 
  • A nurse will contact you to schedule a 1:1 session regarding any errors noted during the claim review
  • Provider will be given at least 45 days from the session to improve
  • If improvement is not seen, provider will move to Round 2 
The goal is to help providers quickly improve. Medicare Administrative Contractors (MACs) work with the providers, in person, to identify errors and assist with correction
Provider/facility receives written notification at the end of the review
  • Medical review will also provide you a written notification at the end of the review to include your results
  • This letter will include:
    • The number of claims reviewed
    • The number of claims allowed in full
    • The number of claims denied in full or in part
    • Limited education on the results
The purpose of the claim review is to ensure documentation supports the reasonable and necessary criteria of the services billed and follows Medicare rules and regulations

Process: Round 2 of Targeted Probe and Educate

Important tasksKey points (How to execute task?)Reason (Why execute task?)
Second Target and Educate Probe is initiated by Medicare If improvement is not shown after Round 1 
  • Probe: Medicare reviews 20-40 claims per provider/facility
The purpose of the claim review is to ensure documentation supports the reasonable and necessary criteria of the services billed and follows Medicare rules and regulations
If Medicare finds the claims to be compliant, the Probe is discontinued for 12 months or more
  • Continue with adequate documentation
You may be released from further review after any round if your documentation shows the required improvement
If Medicare finds the claims to be non-compliant, then "Educate" may occur 
  • A nurse will contact you to schedule a 1:1 session regarding any errors noted during the claim review
  • Provider will be given at least 45 days to improve
  • If improvement is not seen, provider will move to Round 3 
The goal is to help providers quickly improve. Medicare Administrative Contractors (MACs) work with the providers, in person, to identify errors and assist with correction
Provider/facility will receives written notification at the end of the review
  • Medical review will also provide you a written notification at the end of the review to include your results
  • This letter will include:
    • The number of claims reviewed,
    • The number of claims allowed in full
    • The number of claims denied in full or in part
    • Limited education on the results
The purpose of the claim review is to ensure documentation supports the reasonable and necessary criteria of the services billed and follows Medicare rules and regulations

Process: Round 3 of Targeted Probe and Educate

Important tasksKey points (How to execute task?)Reason (Why execute task?)
Third Target and Educate Probe is initiated by Medicare If improvement is not shown after Round 2 
  • Probe: Medicare reviews 20-40 claims per provider/facility
The purpose of the claim review is to ensure documentation supports the reasonable and necessary criteria of the services billed and follows Medicare rules and regulations
If Medicare finds the claims to be compliant, Probe is discontinued for 12 months or more
  • Continue with adequate documentation
You may be released from further review after any round if your documentation shows the required improvement
If Medicare finds the claims to be non-compliant, then "Educate" may occur 
  • A nurse will contact you to schedule a 1:1 session regarding any errors noted during the claim review
  • Provider will be given at least 45 days to improve
  • If improvement is not seen, MAC shall refer the provider to CMS for Possible Further Action
  • This may include 100% pre-pay review, extrapolation, or referral to a recovery auditor (RAC)
The goal is to help providers quickly improve. Medicare Administrative Contractors (MACs) work with the providers, in person, to identify errors and assist with correction
Provider/facility receives written notification at the end of the review
  • Medical review will also provide you a written notification at the end of the review to include your results
  • This letter will include:
    • The number of claims reviewed
    • The number of claims allowed in full
    • The number of claims denied in full or in part
    • Limited education on the results

Any problems that fail to improve after 3 rounds of education sessions will be referred to CMS for next steps. These may include 100 percent prepay review, extrapolation (statistical sampling for overpayment estimation), referral to an auditor, or other action

The purpose of the claim review is to ensure documentation supports the reasonable and necessary criteria of the services billed and follows Medicare rules and regulations

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  

Medicare Administrative Contractor (MAC)Resources
Novitas Solutions, Inc.
  • Sample initial notification letters (Part A: JH / JL ; Part B) [3]
  • Additional documentation checklists (Part A: JH / JL ; Part B) [3]
Palmetto GBA 
  • Target Probe and Educate Process [4]
CSG Administrators 
  • Medical Review Additional Development Request (ADR) Process [5]
First Coast Service Options (FCSO)
  • Responding to additional documentation requests (ADRs) [6]
Noridian Healthcare Solutions
  • How to Respond to ADR [7]
Wisconsin Physicians Service Insurance Corporation (WPS)
  • Documentation Guidance - Hyperbaric Oxygen Therapy G0277 and CPT 99183 [8]
  • Targeted Probe and Educate Topics [9]
  • National Government Services Inc (NGS)
  • Target Probe and Educate; Additional Development Request Letters[10]
  • TPE FINDINGS - HBOT

    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

    Error CodeComments
    HBO2X: There is no documentation of initial and repeated wound measurements during 30 days of conservative treatment for diabetic wound management.
    Regulations are specific in the need to evaluate the condition for which the patient is receiving HBO treatment at least every 30 days during therapy.  HBO therapy is not considered a reasonable service if there are no measurable signs of healing. Vague wording such as ‘improvement noted’ should be avoided. Has there been a reduction in the wound size or appearance? What is/are the patient current symptoms, is this a change?
    HB11A: The decision to deny is based on a Local Coverage Determination (LCD) or an Article (LCA) for medical review based on the National Coverage Determination (NCD) for Hyperbaric Oxygen (HBO) therapy.
    WPS GHA completes the review of HBO claims based on the National Coverage Determination (NCD) 20.29 for HBO therapy. Documentation must support one of the 15 covered conditions. How long has the condition affected the patient? What diagnostics where used in supporting the presents of the condition? 
    HBO3A: Documentation provided indicates less than 30 days of standard wound care treatment was completed for diabetic wound management.
    Per the NCD for Hyperbaric Oxygen Therapy (20.29) state, “The use of HBO therapy is covered as adjunctive therapy only after there are no measurable signs of healing for at least 30–days of treatment with standard wound therapy and must be used in addition to standard wound care.” WPS GHA Medical Review attempts to obtain missing required documentation to assist in avoiding easily curable errors.  Maintaining open communication with the point of contact is essential to avoiding a denial based on insufficient documentation. To avoid denials, include all of the documentation listed in the topic "HBO Documentation Checklist".

    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

    DateDescription
    07/07/2019Expanded sections on Additional Documentation Requests and TPE Findings

    Official reprint from WoundReference® woundreference.com ©2018 Wound Reference, Inc. All Rights Reserved
    Use of WoundReference is subject to the Subscription and License Agreement. ​
    NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.

    REFERENCES

    1. CMS.Gov. CMS.Gov Centers for Medicare and Medicaid Services Targeted Probe and Educate . 2018;.
    2. . CMS Internet-Only Manuals (IOMs) Publication 100-03, Chapter 1, Part 1, Section 20.29, Hyperbaric Oxygen Therapy .;.
    3. Novitas Solutions. Targeted Probe and Educate .;.
    4. Palmetto GBA. Targeted Probe and Educate (TPE) Process Palmetto GBA .;.
    5. CGS Medicare. Medical Review Additional Development Request (ADR) Process . 2019;.
    6. FCSO Medicare. Responding To Additional Documentation Requests (ADR) . 2019;.
    7. Noridian Healthcare Solutions. Noridian How to Respond to ADR . 2019;.
    8. WPS Government Health Administrators. Hyperbaric Oxygen Therapy G0277 and CPT 99183 – Physician or Other Qualified Health Care Professional Attendance and Supervision of Hyperbaric Oxygen Therapy, Per Session . 2017;.
    9. WPS Government Health Administrators J5 Part A. Targeted Probe and Educate Topics . 2018;.
    10. National Government Services: Medicare University. Target Probe and Educate; Additional Development Request Letters . 2019;.
    11. Schaum KD. Are You Following Your Reimbursement "Playbook"? Advances in skin & wound care. 2019;volume 32(7):295-296.
    12. Novitas Solutions. Novitas GHA J5A Targeted Probe & Education (TPE) 5PEF1 .;.
    Topic 1073 Version 2.0