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Providers in AR, CO, LA, MS, NM, OK, TX, Indian Health & Veteran Affairs

Targeted Probe and Educate

TPE Topics for Review

Reprobes Prior to TPE

Low Volume TPE

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:

Provider reviews will consist of three rounds of a prepayment TPE process. Novitas will select the topics for review and providers based on existing data analysis procedures outlined in CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 2.
Novitas will notify providers in writing of the topic being reviewed, the reasons for selection which will be supported by data analysis, and the process of review.
Novitas may refer providers/suppliers to the RA contractor or to the ZPIC/UPIC if providers do not respond to additional documentation requests (ADR).
Education will be offered to the provider throughout the TPE process. Additionally, at the end of each "round of reviews," Novitas will provide notification in writing the results of the claim reviews and will provide education on the potential errors identified. Providers with a moderate or major error classification will receive an offer for one-on-one education related to the specific errors identified. The goal is for providers to learn from education and improve their claim review results in the next "round of reviews." The goal is to achieve no errors or a minor error classification.
Providers will be moved to another round of review if the error rate remains at a moderate or major error classification.
Once a provider has reached a minor error classification, they will be removed from review of that service and Novitas will continue to monitor their claims data on a proactive, routine basis.
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.

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.

An example of the Additional Development Request that will be received related to TPE is linked below: 

All topics for review are listed with a link to education that will assist in ensuring a successful review.

TPE Topics for Review

*To print the documentation checklists, click the links and click the icon in the upper right-hand corner.

Edit

Topic

Documentation Needed

Helpful Hints

Round 1 Dates

Round 2 Dates

Round 3 Dates

5HHD1

5HHD2

90999 – End Stage Renal Disease (ESRD)

Checklist: End Stage Renal Disease (ESRD) Documentation

Achieving a Successful End Stage Renal Disease (ESRD) Review

Initial Letter

Start Date: 9/1/2017

End Date: 1/15/2018

Results

Start Date: 5/1/2018

Results:

TBD

TBD

5HE01

90999 – End Stage Renal Disease (ESRD)

Checklist: End Stage Renal Disease (ESRD) Documentation

Achieving a Successful End Stage Renal Disease (ESRD) Review

Initial Letter

Start Date: 4/1/2018

Results: TBD

TBD

TBD

5HKW1

E41 and E43- Severe Malnutrition

Checklist: Documenting Malnutrition (E41 and E43)

Contact assigned Clinical Reviewer if selected

Initial Letter

Start Date:

12/1/2017

End Date:
4/30/2018

Results

Start Date:

7/1/2018

Results:

TBD

TBD

5HIN1

J0897- Denosumab 1 mg (Prolia/Xgeva)

Checklist: Denosumab (Prolia) Injections Documentation

Contact assigned Clinical Reviewer if selected

Initial Letter

Start Date: 12/1/2017

End Date: 3/31/18

Results

Start Date:

5/1/2018

Results:

TBD

TBD

5HR01

Inpatient Rehabilitation Facility (IRF)

Checklist: Inpatient Rehabilitation (IRF) Documentation

Contact assigned Clinical Reviewer if selected

Initial Letter

Start Date: 2/1/2018

Results: TBD

TBD

TBD

5HR11

Inpatient Rehabilitation Facility (IRF) Based on billing of CMG X20XXX

Checklist: Inpatient Rehabilitation (IRF) Documentation

Contact assigned Clinical Reviewer if selected

Initial Letter

Start Date: 2/1/2018

Results: TBD

TBD

TBD

5HS01

Skilled Nursing Facility (SNF)

Checklist: Skilled Nursing Facility (SNF) Documentation

Contact assigned Clinical Reviewer if selected

Initial Letter

Start Date: 2/1/2018

Results: TBD

TBD

TBD

5HH11

G0277-Hyperbaric oxygen under pressure- (HBO)

Checklist: Hyperbaric oxygen under pressure- (HBO)

Contact assigned Clinical Reviewer if selected

Initial Letter

Start Date: 4/1/2018

Results: TBD

TBD

TBD

5HV21

Intravenous Immunoglobulin (IVIG)

Checklist: Intravenous Immunoglobulin (IVIG)

Contact assigned Clinical Reviewer if selected

Initial Letter

Start Date: 4/15/2018

Results: TBD

TBD

TBD

5HCF1

Comprehensive Outpatient Rehabilitation Facility

(CORF)

Checklist: Comprehensive Outpatient Rehabilitation Facility (CORF)

Contact assigned Clinical Reviewer if selected

Start Date: 5/1/2018

Results: TBD

TBD

TBD

Reprobes Prior to TPE

*To print the documentation checklists, click the links and click the icon in the upper right-hand corner.

Edit

Topic

Documentation Needed

Helpful Hints

Round 1 Dates

Round 2 Dates

Round 3 Dates

5HRF2

Inpatient Rehabilitation Facility (IRF)

Checklist: Inpatient Rehabilitation (IRF) Documentation

Contact assigned Clinical Reviewer if selected

Initial Letter

Previous probe completed in 2017.

Start Date: 12/1/2017

Results

TBD

5HSN2

Skilled Nursing Facility (SNF)

Checklist: Skilled Nursing Facility (SNF) Documentation

Contact assigned Clinical Reviewer if selected

Initial Letter

Previous probe completed in 2017.

Start Date: 12/1/2017

Results

TBD

5HNM2

Cardiovascular Nuclear Medicine

Checklist: Cardio Vascular Nuclear Medicine Documentation

Contact assigned Clinical Reviewer if selected

Initial Letter

Previous probe completed in 2017.

Start Date: 12/1/2017

Results

TBD

Low Volume TPE Topics for Review

*To print the documentation checklists, click the links and click the icon in the upper right-hand corner.

Edit

Topic

Documentation Needed

Implemented Date

5H162

J1786 Imiglucerace - 10 units

Checklist: J1786 Imiglucerase, 10 units Documentation

3/2/2016

5H163

J9228 Ipiliumumab - 1 mg

Checklist: J9228 Ipiliumumab, 1mg Documentation

3/2/2016

5H165

Q2043 Sipuleucel T-per infusion

Checklist: Q2043 Sipuleucel-T, per infusion Documentation

3/2/2016

5H078

ICD-9: 260 ICD-10: E40, E42 Kwashiorkor/Marasmic Kwashiorkor >3 day length of stay

Checklist: E40, E42 Kwashiorkor/Marasmic Kwashiorkor Documentation

8/25/2015

56770

Demand Bill (SNF)

 

1/1/1996


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Last modified:  04/20/2018