Targeted Probe and Educate Progress Update: Ambulance Services A0426-A0428
The Centers for Medicare & Medicaid Services (CMS) Change Request 10249 (PDF, 241.88 KB) implemented the Targeted Probe and Educate (TPE) process, effective October 1, 2017. The following provides JJ TPE Probe results statistics from January 2, 2018, to February 28, 2020.
Findings
Medical Review initiated Probe review edits for providers identified through data analysis demonstrating high risk for improper payment. Providers have been offered education throughout and upon completion of the Probe TPE review. Current JJ Part B Probe: Ambulance Services A0426–A0428 TPE Results are as follows:
Ambulance Services A0426–A0428
Probes Processed January 2, 2018, to February 28, 2020
| Number of Providers with Edit Effectiveness Performed from January 2, 2018 – February 28, 2020, Probe 1 | Providers Compliant Completed/Removed After Probe 1 Edits | Providers Non-Compliant Progressing to TPE Probe 2 | Providers Non-Compliant/Removed for Other Reason |
|---|---|---|---|
|
57 |
14 |
40 |
3 |
| Number of Providers with Edit Effectiveness Performed from January 2, 2018 – February 28, 2020, Probe 2 | Providers Compliant Completed/Removed After Probe 2 Edits | Providers Non-Compliant Progressing to TPE Probe 3 | Providers Non-Compliant/Removed for Other Reason |
|---|---|---|---|
|
16 |
6 |
7 |
0 |
Findings by State
Palmetto GBA’s overview of results by state, for providers who have had edit effectiveness performed, for Probe 1 TPE review from January 2, 2018, to February 28, 2020.
| State | Number of Providers with Edit Effectiveness Performed from January 2, 2018 – February 28, 2020 Probe 1 | Providers Compliant Completed/Removed After Probe 1 | Providers Non-Compliant Progressing to TPE Probe 2 | Providers Non-Compliant/Removed for Other Reason | Overall Charge Denial Rate Per State |
|---|---|---|---|---|---|
| Alabama |
8 |
2 |
6 |
0 |
54% |
| Georgia |
40 |
8 |
29 |
3 |
69% |
| Tennessee |
9 |
4 |
5 |
0 |
49% |
| State | Number of Providers with Edit Effectiveness Performed from January 2, 2018 – February 28, 2020 Probe 2 | Providers Compliant Completed/Removed After Probe 2 | Providers Non-Compliant Progressing to TPE Probe 3 | Providers Non-Compliant/Removed for Other Reason | Overall Charge Denial Rate Per State |
|---|---|---|---|---|---|
| Alabama |
3 |
2 |
1 |
0 |
40% |
| Georgia |
10 |
5 |
5 |
0 |
35% |
| Tennessee |
3 |
2 |
1 |
0 |
13% |
Risk Category
Risk Category is defined based on end of Probe 1 provider error rates. The categories are defined as:
| Risk Category | Error Rate |
|---|---|
|
Minor |
0–20% |
|
Major |
21–100% |
Risk Category
Risk Category is defined based on end of Probe 2 provider error rates. The categories are defined as:
| Risk Category | Error Rate |
|---|---|
|
Minor |
0–20% |
|
Major |
21–100% |
Ambulance Services Probe 1
Top 5 Denial Reasons January 2, 2018, to February 28, 2020
- NOTMN — Payer deems the information submitted does not support medical necessity of services billed
- INPSC — Invalid physician certification statement
- BNSIG — Documentation received lacks the necessary beneficiary or authorized representative signature
- NODOC — Documentation not received timely
- NOPSC — No physician certification statement submitted in the medical record
Ambulance Services Probe 2
Top 5 Denial Reasons January 2, 2018, to February 28, 2020
- NOTMN — Payer deems the information submitted does not support medical necessity of services billed
- INPSC — Invalid physician certification statement
- NODOC — Documentation not received timely
- ATCCH — Transportation is only covered to the closest facility that can provide the necessary care
- WRONG — Documentation received contains incorrect/incomplete/invalid patient identification or date of service
NOTMN
Payer deems the information submitted does not support the medical necessity of the services billed.
- Ensure that all documentation to support medical necessity of the service billed is submitted for review. This includes original chart notes and any diagnostic, radiological, or laboratory results.
- Verify that documentation to support the level of service billed is included. Please refer to the website at www.PalmettoGBA.com for links to applicable LCDs, NCDs and the E/M Scoresheet Tool for documentation requirements.
INPSC
Invalid physician certification statement.
• Review documentation prior to submission to ensure that the complete signed certificate of medical necessity is included
BNSIG
Documentation received lacks the necessary beneficiary or authorized representative signature.
- Review documentation prior to submission to ensure that the proper beneficiary or authorized representative signature is included and is legible
- For illegible signatures, clearly print or type the full name of the owner of the signature
NODOC
Documentation not received timely.
- Be aware of the ADR date and the need to submit medical records within 45 days of the ADR date
- Submit the medical records as soon as the ADR is received
- Monitor the status of your claims in Direct Data Entry (DDE) and begin gathering the medical records as soon as the claim goes to the location of SB6001
- Return the medical records to the address on the ADR. Be sure to include the appropriate mail code or station number. This ensures that your responses are promptly routed to the Medical Review Department.
- Gather all the information needed for the claim and submit it all at one time
- Attach a copy of the ADR request to each individual claim
- If responding to multiple ADRs, separate each response and attach a copy of the ADR to each individual set of medical records. Make sure each set of medical records is bound securely with one staple in the upper left corner or a rubber band to ensure that no documentation is detached or lost. Do not use paper clips.
- Do not mail packages C.O.D.; we cannot accept them
NOPSC
No physician certification statement submitted in the medical record.
- Review documentation prior to submission to ensure that a complete signed certification statement is included
ATCCH
Transportation is only covered to the closest facility that can provide the necessary care.
- Ensure that the appropriate modifier (GZ or GA) is used for billing claims for non-emergent or non-medically necessary runs when the patient has been informed in advance that the service is expected to be denied by Medicare as not reasonable and necessary
- Ensure that documentation supports medical necessity of destination
WRONG
Documentation received contains an incorrect/incomplete/illegible patient identification or date of service.
- Review all documentation prior to submission to ensure that it is for the correct patient and date of service
- Ensure that patient identifiers are legible and complete
- Ensure that the complete date of service is clearly and legibly noted on all documentation
- Prior to billing claims, review the information to determine that the correct patient identifier and the correct date of service are listed in the appropriate field
Education
Providers are offered an individualized education session where each claim denial will be discussed, and any questions will be answered. Palmetto GBA offers a variety of methods for provider education such as webinar sessions, web-based presentations, or teleconferences. Other education methods may also be available.
Next Steps
Providers found to be non-compliant (major risk category/denial rate of 21–100%) at the completion of TPE Probe 1 will advance to Probe 2, and providers found to be non-compliant (major risk category/denial rate of 21–100%) at the completion of TPE Probe 2 will advance to Probe 3 of TPE at least 45 days from completion of the 1:1 post probe education call date. Palmetto GBA offers education at any time for providers. Providers do not have to be identified for TPE to request education.
References
- CMS Targeted Probe and Educate (TPE) web page
- Change Request 10249 (PDF, 241.88 KB)