Targeted Probe and Educate Progress Update: Inpatient Rehab Facility A0604, B0604, C0604 and D0604


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 JM TPE Probe results statistics from October 1, 2017 to January 31, 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 JM Probe Part A Inpatient Rehab Facility TPE Results are as follows:

Inpatient Rehab Facility

Probes Processed October 1, 2017 – January 31, 2020

Number of Providers with Edit Effectiveness Performed from Oct. 1, 2017 – January 31, 2020 Probe 1 Providers Compliant Completed/Removed After Probe 1 EditsProviders Non-Compliant Progressing to TPE Probe 2Providers Non-Compliant/Removed for Other Reason

1

0

1

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 to January 31, 2020.

StateNumber of Providers with Edit Effectiveness Performed from Oct. 1, 2017 – January 31, 2020 Probe 1Providers Compliant Completed/Removed After Probe 1Providers Non-Compliant Progressing to TPE Probe 2Providers Non-Compliant/Removed for Other Reason Overall Charge Denial Rate Per State
North Carolina

N/A

N/A

N/A

N/A

N/A

South Carolina

1

0

1

0

29%

Virginia

N/A

N/A

N/A

N/A

N/A

West Virginia

N/A

N/A

N/A

N/A

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%


         
Inpatient Rehab Facility

Top Denial Reasons October 1, 2017 to January 31, 2020

  1. 5J504/5K504 — Need for Services Not Medically and Reasonably Necessary

 

5J504/5K504 — Need for Services Not Medically and Reasonably Necessary

Reason for Denial
The claim has been fully or partially denied as the documentation submitted for review did not support the medical necessity of the services provided.

How to Avoid a Denial
Documentation and tips that may be helpful to avoid future denials for this reason may include, but are not limited to, the following:

  • Submit documentation to support that services were medically necessary on an inpatient basis instead of a less intensive setting
  • Documentation should include all clinical information for the dates of service billed such as physician progress notes, physical examinations, assessments, diagnostic tests and laboratory test results, history and physical, nurse’s notes, consultations, surgical procedures, orders and discharge summary and any other documentation to support the inpatient admission
  • Include documentation of services, medication and medical interventions performed in the Emergency Department
  • For elective surgical procedures, include documentation to support the necessity of the procedure including pre-surgical interventions and outcomes

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 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





Last Updated: 03/18/2020