Medical Review

Resumption of Postpayment Medical Reviews

As recently published at MACs Resume Medical Review on a Postpayment Basis, Medicare Administrative Contractors (MACs) resumed fee-for-service medical review activities to protect the Medicare Trust Fund against inappropriate payments. Effective September 1, 2021, the MACs will discontinue sending postpayment additional documentation requests (ADR) and will resume reviews  conducted under the Targeted Probe and Educate (TPE) Medical Review Strategy.  Providers should continue responding to Postpayment ADR requests already issued. Please continue to refer to information outlined in Receiving and Receiving and Responding to a Palmetto GBA Additional Documentation Request (ADR) for Postpayment Review. For more information on TPE please visit Targeted Probe and Educate.

Medical review is the collection of information and clinical review of medical records by Palmetto GBA to ensure that payment is made only for services that meet all Medicare coverage, coding and medical necessity requirements. Medical review activities are directed toward areas where data analyses indicate questionable billing patterns.

The goal of the medical review program is to reduce payment errors by identifying and addressing billing errors made by providers concerning coverage and coding. To achieve the goal of the medical review program, Palmetto GBA:

  • Proactively identifies patterns of potential billing errors concerning Medicare coverage and coding made by providers through data analysis and evaluation of other information (e.g., complaints);
  • Reviews data analysis reports;
  • Takes action to prevent and/or address the identified error;
  • Publishes local medical review policies via Local Coverage Determinations (LCDs) to provide guidance to the public and medical community about when items and services will be eligible for payment under the Medicare statute

Additional Resources

Medical Review Articles

56900 - Auto Deny - Requested Records Not Submitted5FT10 and 5AT10 - Documentation Does Not Support Homebound Status5CF36 - Not Hospice Appropriate5F041 and 5A041 - Information Provided Does Not Support Medical Necessity for this Service5FF2F and 5TF2F - Face-to-Face Encounter Requirements Not MetTargeted Probe and Educate Progress Update: Hospice - NCLOS5CFH6 - Initial Certification Not TimelyTargeted Probe and Educate Progress Update: Hospice - Beneficiary Sharing5A301 - Information Provided Does Not Support the Medical Necessity for Therapy Services5CNER - The Notice of Election Statement Is Invalid Because It Doesn't Meet Statutory/Regulatory Requirements5FFH9 - Physician Narrative Statement Not Present or Not ValidTargeted Probe and Educate Progress Update: Hospice - GIP - General Inpatient Care5F072 - No Physician's Order for Services or More Than OrderedHospice Routine Home Care Targeted Probe and Educate (TPE) Refinement5CFTF - Face-to-Face Encounter Requirements Not Met5CFNP - No Plan of Care SubmittedTargeted Probe and Educate Progress Update: Hospice - NCLOS5CF91 - Hospice GIP Reduction - Services Not Reasonable/NecessaryTargeted Probe and Educate Progress Update: Home Health Progress Update5CNOE - No Valid Election Statement Submitted5CFH9 - Physician Narrative Statement Not Present or Not Valid5CFIP - Invalid Plan of Care SubmittedTargeted Probe and Educate Progress UpdateTargeted Probe and Educate Progress Update for JM Home Health Bene Sharing5FNOA - Unable to Determine Medical Necessity of HIPPS Code Billed as Appropriate OASIS Not Submitted5F023 - No Plan of Care or Certification5CF01 - General Inpatient Services Not Reasonable and Necessary5CFH4 - Initial Certification Not Signed5FF2F - Face-to-Face Encounter Requirements Not Met5CHG3 - MR HIPPS Code Change Due to Partial Denial of TherapyMedical Review Administrative Relief Related to the Novel Coronavirus (COVID-19) PandemicTargeted Probe and Educate VideoTargeted Probe & Educate (TPE) Provider ContactMedical Review Intent to Reopen Process for Non-Receipt of Medical Record DenialsPalmetto GBA Partnering with Providers to Get it Right the First TimeWe Have Noticed a Significant Increase in 56900 Auto Denials - Requested Records Not SubmittedActive Service Specific Postpayment Medical ReviewsResponding to a Hospice Additional Documentation RequestHospice Certification ErrorsHome Health Denials for Incorrect Billing of 'Attending/Other' Names and NPIsHome Health: Therapy ADRsHospice Documentation TipsHHH Denial Reason Code CrosswalkResponding to a Home Health Additional Documentation Request (ADR)Non-Physician Practitioners and the Face to Face EncounterReceiving and Responding to a Palmetto GBA Additional Documentation Request (ADR) for Postpayment ReviewCharge Denial Rate (CDR) CalculatorComplying with Medicare Signature RequirementsMedical Review Program and Targeted Probe and Educate HandoutTargeted Probe and Educate Process ModuleAccess TPE Letters Electronically Job AidMedicare Record Authentication: Tips for PhysiciansADR Response Calculator5T070 - Visits/Supplies/DME Billed Not Documented/Not Documented As UsedTargeted Probe and Educate Progress UpdateHome Health Postpayment Results for October to December 2020 Postpayment Service-Specific Probe Results for Hospice (General Inpatient Care) for October through December 2020CMS MLN Fact Sheet: Medical Record Maintenance and Access RequirementsMACs Resume Medical Review on a Postpayment BasisHome Health Medical Review Top Denial Reason Codes: January through March 2021JM Part A, Part B and Home Health and Hospice Targeted Probe and Educate (TPE) Active Medical Review ListClaim Selection Process for Targeted Probe and Educate: S B6000 vs. S B6001Targeted Probe and Educate Resumed September 1, 2021Medicare Medical Records: Signature Requirements, Acceptable and Unacceptable PracticesPostpayment Service-Specific Probe Results for Hospice General Inpatient Care for January through March 2021Postpayment Service-Specific Probe Results for Home Health for January through March 2021Medicare Medical Review Hot Topics Webinar: Resumption of Targeted Probe and Educate for Jurisdictions J, M, HHH and Railroad on September 22, 2021