Targeted Probe and Educate Progress Update: JJ Ambulance A0427-A0429: Ambulance Services (Emergent)

The Centers for Medicare & Medicaid Services (CMS) Change Request 10249 (PDF, 241.88 KB) implemented the Targeted Probe & 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 Probe 1, Part B TPE Ambulance A0427–A0428 Emergent Results are as follows:

Ambulance A0427–A0429: Ambulance Services (Emergent)

Probes Processed January 2, 2018, to February 28, 2020

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.

Risk Category
Risk Category is defined based on end of Probe 1 provider error rates. The categories are defined as:

Ambulance — A0427–A0429 — Ambulance Services (Emergent)

Top 5 Denial Reasons January 2, 2018, to February 28, 2020

1. NOTMN — Payer deems the information submitted does not support the medical necessity of the services billed
2. WRONG — Documentation received contains an incorrect/incomplete/illegible patient identification or date of service
3. NODOC — Documentation requested for this date of service was not received or was incomplete
4. INPSC — Invalid physician certification statement
5. NORUN — Documentation received lacks the necessary run report

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.

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 ADR’s, 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

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

INPSC
Invalid physician certification statement.

• Review documentation prior to submission to ensure that the complete signed certificate of medical necessity is included

NORUN
Documentation received lacks the necessary run report.

• Review documentation prior to submission to ensure that a complete legible run report is included

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)