targeted probe and educate review process

Targeted Probe and Educate Review Process

American College of Osteopathic Internists Annual Convention

October 30, 2019

Confidential & Proprietary

Targeted Probe and Educate

Review Process(Claims I wish you never would have submitted!)

Ella Noel, DO, FACOI

J8 Contractor Medical Director

Wisconsin Physicians Service Insurance Corporation



October 30, 2019


Thank You

• I would like to acknowledge Gerald Blackburn, DO, for his suggestion of a title for this lecture and his long-term commitment to the education of physicians, physicians in training and medical students.



October 30, 2019


Financial Disclosures

• I have no financial disclosures to make.



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Objectives

• Define waste, abuse, and fraud.

• Understand goals of Targeted Probe and Educate Review process.

• Understand how to avoid common errors in claims



October 30, 2019


Medicare Alphabet Soup

• MAC: Medicare Administrative Contractor



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Medicare Alphabet Soup

• CMD: Contractor Medical Director

• MR: Medical Review

• NA: Nurse Analyst

• ADR: Additional Documentation Request

• CERT: Comprehensive Error Rate Testing Program

• UPIC: Unified Program Integrity Contractor

• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Acronyms/Acronyms-908999.html

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Acronyms/Acronyms-908999.html



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Medicare Definitions

• Waste: Practices that, directly or indirectly, result in unnecessary costs to the Medicare Program, such as overusing services. This is not caused by criminally negligent actions and the misuse of resources.

• Abuse: Practices that, directly or indirectly, result in unnecessary costs to the Medicare. Any activity that does not meet professionally recognized standards or provide patients with medically necessary services. This is illegal.

– Billing for unnecessary services (not medically necessary)

– Overcharging for services or supplies

– Misusing billing codes to increase reimbursement



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Medicare Definitions

• Fraud: Occurs when someone knowingly deceives Medicare to receive payment when they should not, or to receive higher payment that they should. This is illegal.

– Bill Medicare for services you never performed

– Bill Medicare for services that are different from the ones you performed (usually more expensive!)

– Continue to bill Medicare for rented medical equipment after beneficiaries have returned it

– Offer or perform services that beneficiaries do not need in order to charge Medicare for more services

– Telling beneficiary Medicare will pay for something and it will not

– Using someone else’s Medicare number or card



October 30, 2019


What is Targeted Probe and Educate (TPE)?

• Medical review practice for the Medicare Administrative Contractors (MAC) for Parts A and B.

• Change Request 10294.

• This started in October 2017.

• The goal is increased accuracy in claims submitted in very specific areas by using data analysis to identify select providers and providing education.

• The MACs are looking for high claim error rates OR unusual billing practices and items and services that have high national error rates and are a financial risk to Medicare.



October 30, 2019


So you got picked for TPE…

Dear Medicare Provider or Supplier:

In order to fulfill our contractual obligation with the Center for Medicare & Medicaid Services (CMS), Wisconsin Physician Services Government Health Administrators (WPS GHA) your Jurisdiction 8 Medicare Administrative Contractor (MAC), performs reviews in accordance with the CMS instruction. CMS has authorized Jurisdiction 8 to conduct the Targeted Probe and Educate (TPE) review process.



October 30, 2019


So you got picked for TPE…

The TPE review process includes three rounds of a prepayment probe review with education. You may be released from further review after any round if your documentation shows the required improvement. If there are continued high denials after three rounds, WPS GHA will refer the provider/supplier to CMS additional action, which may include 100% prepay review, extrapolation, referral to a Recovery Auditor, etc. Note, discontinuation of review may occur at any time if appropriate improvement is achieved during the review process.



October 30, 2019


So You Got Picked for TPE…

This letter serves as notice that you have been selected for a TPE claim review. 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.

Reason of Review

Your facility was selected for review based on data analysis. A prepayment review has been initiated to probe a sample of 20-40 claims billed with following XXXXX code(s).



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Additional Documentation Requests

Please do not send any documentation at this time. The claims processing system will notify you of the Additional Documentation Request (ADR) for each claim selected for review. The ADR will include a list of suggested documentation needed to support the service on review. Please ensure the process for routing ADRs to the person(s) responsible for submission is timely and effective. Inform your staff responsible for receiving the ADR letters and submitting the required documentation of this review. Authorization for the collection of this information included in Federal Law at SSA 1833 (e) and in Federal Regulation at 42 CFR 424.5(a)(6).



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Education will be provided both intra-probe and post-probe. As a provider, you will be able to ask questions during these 1:1 educational opportunities. Upon completion of the claim sample, the nurse reviewer will contact you to schedule a 1:1 educational session regarding any errors noted during the claim review. Medical Review will also provide you 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 and limited education on the results.



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In addition, we remind you that our regulation at 42 CFR §424.535 authorizes us to revoke Medicare billing privileges under certain conditions. In particular, we note that per 42 CFR §424.535(a)(8)(ii), CMS has the authority to revoke a currently enrolled provider or supplier’s Medicare billing privileges if CMS determines that the provider or supplier has a pattern or practice of submitting claims that fail to meet Medicare requirements.



October 30, 2019


Examples of Current Topics for Part B TPE

• Current topic(s) under review:

– Hyperbaric Oxygen Therapy G0277 and CPT 99183 – Physician or Other Qualified Health Care Professional Attendance and Supervision of Hyperbaric Oxygen Therapy, Per Session

– Outpatient Evaluation and Management Service CPT Code 99211-99215 – Office or Other Outpatient Visit for Evaluation and Management of an Established Patient

– Inpatient Evaluation and Management Service CPT Code(s) 99221-99223 – Initial Hospital Care

– CPT code 90853: Group Psychotherapy

– Drug Testing HCPCS Code(s) G0483



October 30, 2019


Examples of Current Topics for Part A TPE

• Current topic(s) under review:

– Hyperbaric Oxygen Therapy G0277– Physician or Other Qualified Health Care Professional Attendance and Supervision of Hyperbaric Oxygen Therapy, Per Session

– Skilled Nursing Facility (SNF) RUG Utilization

– Inpatient Rehabilitation Facility or Unit (IRF/IRU)

– CPT Codes 99281-99285 Emergency Department Visits

– Diagnostic Related Group (DRG) Validation

– Outpatient Observation

– Outpatient Therapy CPT Code 97110



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Examples of Future TPE Topics

• Wound Care

• Foot Care

• CPT 97110

• Non-emergent ambulance transport

• Botox

• Total knee arthroplasty

• Critical Care



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What’s the Good News?

• Most providers never get picked for TPE.

• Even if you do get picked, most providers see improvement in the accuracy of their claims.

• Once your error rate is less than 20% you will be removed from TPE for that topic.

• If compliant with improvement, you cannot be reviewed on that topic for one year.

• You can be reviewed for other problems within that year.



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TPE Housekeeping

• You will be asked about a Point of Contact. The MACs want to reach out to the correct person for education about the reviewed claims.

• Documentation for ADR can be sent through:

– Portal

– Mail

– Fax

• You can also see any ADR letters in the Portal.



October 30, 2019


TPE Review of Claims with CPT 99223

• CPT 99223 Initial hospital care requires 3 key components:

– Comprehensive history

– Comprehensive examination

– Medical decision making of high complexity



October 30, 2019


Claim #1 Billed with CPT 99223

• 75 y/o female presents to ER with SOB and palpitations. Patient has history of chronic atrial fibrillation. No CP. No cough. Notes no peripheral edema. SOB with exertion. No PND or orthopnea. No fever or chills. Compliant with usual meds. Denies CHF history. Last echocardiogram 2 years ago. States had normal stress test 1 year ago.

• PMHx/PSHx/Social Hx/FHx/Allergies/Medications/ROS completed.

• PE included head, neck, chest, abdomen, back, genitalia and extremities examination. Vital signs were recorded in note.



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Case #1 Billed with 99223

• Assessment:

– Chronic atrial fibrillation-rate currently controlled

– SOB resolved

– HTN

– Hypothyroidism

• Plan:

– Continue current medications

– Increase activity

– Continue to monitor symptoms

• Signature was placed electronically



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Most Common Claim Errors

• No signature included.

• Documentation does not meet medical necessity.

• Encounter notes did not support all elements of eligibility.

• Missing or incomplete initial certification or recertification.



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Comprehensive History

• Comprehensive history consists of:

– Chief complaint

– Extended history of present illness

– ROS related to problem(s) in history of present illness

– ROS of remaining body systems

– Complete past, family and social history



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Comprehensive Examination

• Comprehensive examination is a general multisystem examination or a complete examination of a single organ system.

• This can be organized in body areas or organ systems.



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Complexity of Medical Decision Making

• High Complexity Medical Decision-Making Requirements

– Extensive number of diagnoses or management options

– Extensive amount or complexity of data to be reviewed

– High risk of complications and/or morbidity or mortality



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• The provider did not meet the criteria for high complexity of medical decision making

• Suspect that this claim was “missing” documentation:

– CXR

– EKG

– Cardiac Monitor

– PT monitoring

– Labs that were done or needed to be done



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• If you do not document what you are doing, it did not happen!

• This claim was reviewed and down coded to 99221.

• Provider would be educated on documentation requirements.



October 30, 2019


Need More Information?



October 30, 2019


Documentation Hints



October 30, 2019


TPE Review of CPT 99214

• CPT 99214: Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these 3 key components:

– A detailed history

– A detailed examination

– Medical decision of moderate complexity



October 30, 2019



• C/C is rash in 20 year old male.

• Hx of C/C. Rash for one week. Increasing. Pruritic. Pulled weeds at home 8 days ago. Hx of rhus dermatitis in past.

• PMHx (-). PSHx: Appendectomy. SHx: 1PPD for 2 years. Also had FHx, Complete ROS. Medications: None. Allergies: NKDA.

• PE included HEENT, CV, Resp, GI, MS,Skin, Neurologic, Psych and Lymphatics.



October 30, 2019



• Assessment: Rhus dermatitis.

• Plan: OTC steroid cream TID recommended. Potential side effects discussed. Call or return if not improving.

• Record was signed by provider.



October 30, 2019


So Why Isn’t This Claim Correctly Billed with

CPT 99214?

• CPT defines 99214 as requiring 2 of 3 elements. The claim does have a comprehensive history and exam which more than exceeds the requirements for 99214.

• BUT… the complexity of the decision making is low complexity at best.

– Defined as limited number of diagnoses or management options, limited amount and/or complexity of data to be reviewed, low risk of complications and/or morbidity or mortality and low complexity of type of decision making.



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October 30, 2019


You Did the Work, What’s the Problem?

• Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.

• (Internet Only Manual 100-4, Chapter 12, Section 30.6.1.)

• https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf



October 30, 2019


You Did the Work, what’s the Problem?

• So we’re going to down code this from CPT 99214 to 99213.

• We would educate on this premise.



October 30, 2019



• CPT 99239-Hospital discharge day management more than 30 minutes.

– Report the total duration of time spent by a physician for final hospital discharge of a patient.

– Includes final examination, discussion of hospital stay. Instructions for continuing care and preparation of discharge records, prescriptions and referral forms.



October 30, 2019



• Final progress note reviewed. Following points were noted.

– Date and time of last progress note.

– Patient’s final exam noted.

– Discharge plans and medication reconciliation completed.

– Discharge summary dictated.

– Prescriptions written.

– Referrals completed.

– Face sheet completed.

– Note was signed.



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• Discharge down coded to CPT 99238.

• The provider did not provide a start and stop time or minutes involved.

• Education would be provided.



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October 30, 2019


Summary

• Think of the MACs as a consultant who reviews your claims for accuracy and then provides education to decrease errors in submitted claims.

• We are trying to educate the provider to decrease the improper payment rate.

• This is not part of the appeal process. Providers can appeal any denials after the TPE review process has been completed.



October 30, 2019


Provider Outreach & Education

• Staff work with Medical Review to provide education

– Resources and Guides on the WPS GHA web portal

– WPS GHA Learning Center – wpsghalearningcenter.com

• Contains advertisement for upcoming in-person, teleconferences, and webinars

• Register for any of the educational events

• Contains numerous On Demand courses

– TPE specific – Do a search for TPE and there are four courses

– We have a Facebook page that provides additional information

– We have a You Tube Channel providing short videos on various topics



October 30, 2019


References• https://www.cms.gov/Research-Statistics-Data-and-

Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE.html

• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Acronyms/Acronyms-908999.html

• https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R1919OTN.pdf

• https://www.wpsgha.com/wps/portal/mac/site/home

• https://www.wpsgha.com/wps/portal/mac/site/claim-review/guides-and-resources/targeted-probe-and-educate-topics

• https://www.wpsgha.com/wps/portal/mac/site/claim-review/guides-and-resources/documentation-support-em-service-under-tpe-review

https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE.html

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Acronyms/Acronyms-908999.html

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R1919OTN.pdf

https://www.wpsgha.com/wps/portal/mac/site/home

https://www.wpsgha.com/wps/portal/mac/site/claim-review/guides-and-resources/targeted-probe-and-educate-topics

https://www.wpsgha.com/wps/portal/mac/site/claim-review/guides-and-resources/documentation-support-em-service-under-tpe-review



October 30, 2019


Volunteer as a CAC Member! Assist us in

Developing Local Coverage Determinations.

• The purpose of the CAC is to provide a formal mechanism for healthcare professionals to be informed of the evidence used in consideration of a proposed LCD and to promote communications between the Medicare Administrative Contractor (MAC) and the healthcare community. CAC members serve in an advisory capacity as representatives of their constituency to review the quality of the evidence regarding a topic under consideration for development of a proposed LCD.

• If you would like to volunteer as a representative or alternate, please ask your affiliated National or State Society to provide you with a nomination letter. The completed nomination letter may be sent via email to [email protected]. Please include the following:

mailto:[email protected]



October 30, 2019


Questions or Comments

Thanks for your attention.

Contact information:

[email protected]

To report fraud to Medicare:

1-800-HHS-TIPS

[email protected]

mailto:[email protected]

targeted probe and educate review process

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