Low-Volume TPE Topics
Targeted Probe and Educate Questions and Answers
Targeted Probe and Educate (TPE) is one process that a Medicare Administrative Contractor (MAC) can utilize when providers are selected by Medical Review. The TPE review process includes three rounds of a prepayment probe review with education. If there are continued high denials after the first three rounds of reviews, Novitas will refer the provider and results to the Center for Medicare and Medicaid Services (CMS). CMS will determine additional action, which may include extrapolation, referral to the Zone Program Integrity Contractor (ZPIC) or Unified Program Integrity Contractor (UPIC), referral to the Recovery Auditor (RA) contractor, etc.
Note: Discontinuation of review may occur at any time if appropriate improvement is achieved during the review process.
The key elements of this probe and educate include:
If selected for a TPE review, providers are not excluded from other Medical Review activities such as automated reviews, comparative billing reports, mandated demand bill reviews, other pilot review strategies, etc. as directed by CMS or other contractor reviews. Additionally, Novitas will continue to work with other CMS contractors and collaborate with referrals back and forth to the Quality Integrity Organization (QIO) for quality of care concerns, the ZPIC/UPIC for concerns related to potential fraud and/or abuse, and the RA contractor to ensure there is no duplication of reviews.
All topics for review are listed with a link to education that will assist in ensuring a successful review.
Round 1 Start Date
Round 3 Start Date
90999 – End Stage Renal Disease (ESRD)
Checklist: End Stage Renal Disease (ESRD) Documentation
Achieving a Successful End Stage Renal Disease (ESRD) Review
E41 and E43- Severe Malnutrition
Checklist: Documenting Malnutrition (E41 and E43)
J0897- Denosumab 1 mg (Prolia/Xgeva)
Checklist: Denosumab (Prolia) Injections Documentation
G0277-Hyperbaric oxygen under pressure- (HBO)
Round 2 Start Date
Inpatient Rehabilitation Facility (IRF)
Checklist: Inpatient Rehabilitation (IRF) Documentation
Previous probe completed in 2017.
Skilled Nursing Facility (SNF)
Checklist: Skilled Nursing Facility (SNF) Documentation
Cardiovascular Nuclear Medicine
Checklist: Cardio Vascular Nuclear Medicine Documentation
Imiglucerace - 10 units
Checklist: J1786 Imiglucerase, 10 units Documentation
Ipiliumumab - 1 mg
Checklist: J9228 Ipiliumumab, 1mg Documentation
Sipuleucel T-per infusion
Checklist: Q2043 Sipuleucel-T, per infusion Documentation
ICD-10: E40, E42
>4 day length of stay
Checklist: E40, E42 Kwashiorkor/Marasmic Kwashiorkor Documentation
Demand Bill (SNF)
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