Targeted Probe and Educate Progress Update: DRG 682-683

Published 10/24/2019

The Centers for Medicare & Medicaid Services (CMS) Change Request 10249 (PDF, 242 KB) implemented the Targeted Probe & Educate (TPE) process, effective October 1, 2017. The following provides Probe 1 TPE results statistics from October 1, 2017 – September 30, 2019.

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 1 TPE review. Current Probe 1 DRG 682/683 Renal Failure with MCC/CC TPE Results are as follows:

DRG 682/683 Renal Failure with MCC/CC

Probes Processed October 1, 2017 – September 30, 2019

Number of Providers with Edit Effectiveness Performed from Oct. 1, 2017 – September 30, 2019Providers Compliant Completed/Removed After Probe 1Providers Non-Compliant Progressing to TPE Probe 2Providers Non-Compliant/Removed for Other Reasons

1

1

0

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 October 1, 2017 – September 30, 2019.

StateNumber of Providers with Edit Effectiveness Performed from Oct. 1, 2017 – September 30, 2019Providers Compliant Completed/Removed After Probe 1Providers Non-Compliant Progressing to TPE Probe 2Providers Non-Compliant/Removed for Other ReasonsOverall Charge Denial Rate Per State
N.C.

1

1

0

0

0%

S.C.

0

0

0

0

N/A

Va.

0

0

0

0

N/A

W.Va.

0

0

0

0

N/A

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

Risk CategoryError Rate

Minor

0–20%

Major

21–100%


DRG 682/683 Risk Category October 1, 2017 – September 30, 2019 Pie Chart Major 100% 

DRG 682/683 Renal Failure with MCC/CC

Denial Reason October 1, 2017 — September 30, 2019

  1. No Denials

DRG 682/683 Denials Pie Chart No Denials

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 and teleconferences. Other education methods may also be available.

Next Steps
Providers found to be non-compliant (major risk category/denial rate of 21–100 percent) 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 percent) 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