Targeted Probe and Educate Progress Update: HBO Therapy G0277

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 Probe 1 TPE 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 A Probe 1 Hyperbaric Oxygen (HBO) Therapy G0277 TPE Results are as follows:

HBO Therapy G0277

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

Number of Providers with Edit Effectiveness Performed Jan. 2, 2018 – Feb. 28, 2020
 
Probe 1 Providers Compliant Completed/Removed After Probe 1 Edits Providers Non-Compliant Progressing to TPE Probe 2Providers Non-Compliant/Removed for Other Reason

8

3

5

0

Findings by State
Palmetto GBA’s overview of results by state, for providers who have had edit effectiveness performed for JJ Probe 1 TPE review from January 2, 2018, to February 28, 2020.

StateNumber of Providers with Edit Effectiveness Performed from Jan. 2, 2018- Feb. 28, 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
Alabama

2

0

2

0

37%

Georgia

1

0

1

0

44%

Tennessee

5

3

2

0

11%

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

Risk CategoryError Rate

Minor

0–20%

Major

21–100%

 


 
HBO Therapy G0277

Top 5 Denial Reasons January 2, 2018, to February 28, 2020 JJ Probe 1

  1. 5D920/5H920 — The Recommended Protocol Was Not Ordered and/or Followed
  2. 5D164/5H164 — No Documentation of Medical Necessity
  3. 5DMDP/5HMDP — Dependent Services Denied (Qualifying Service Denied Medically)
  4. 5D151/5H151 — Units Billed More Than Ordered
  5. 5D169/5H169 — Services Not Documented

5D920/5H920 — The Recommended Protocol Was Not Ordered and/or Followed

Reason for Denial
Medicare cannot pay for this service because one or more requirements for coverage were not met.

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

  • Clear physician’s order with indication of need, dose, frequency and route
  • Date and time of associated chemotherapy, as applicable
  • Relevant history and physical and/or progress notes
  • Clear indication of the diagnosis
  • Clinical signs and symptoms
  • Prior treatment and response, as applicable
  • Stage of treatment, as applicable
  • Documentation of administration

5D164/5H164 — No Documentation of Medical Necessity

Reason for Denial
This claim was fully or partially denied because the documentation submitted for review does not support the medical necessity of some of the services billed.

How to Avoid a Denial

  • Submit all documentation related to the services billed which support the medical necessity of the services
  • A legible signature is required on all documentation necessary to support orders and medical necessity
  • Use the most appropriate ICD-10-CM codes to identify the beneficiary’s medical diagnosis

5DMDP/5HMDP — Dependent Services Denied (Qualifying Service Denied Medically)

Reason for Denial
The dependent service(s) will not be covered if the qualifying surgery has been denied. For example, the surgical procedure was denied as documentation did not support medical necessity; therefore, all other charges cannot be allowed and will be denied as dependent to the medical denial of the qualifying service.

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

  • All documentation to support orders, documentation of services rendered and documentation of medical necessity for the qualifying services for the date(s) billed

5D151/5H151 — Units Billed More Than Ordered

Reason for Denial
The physician’s orders submitted did not cover all the units billed.

How to Avoid a Denial
In order to avoid unnecessary denials for this reason, the provider should ensure that the physician’s orders cover all the services to be billed prior to billing Medicare. When responding to an Additional Documentation Request (ADR), ensure that all orders for services billed are included with the medical records.

5D169/5H169 — Services Not Documented

Reason for Denial
This claim was partially or fully denied because the provider billed for services/items not documented in the medical record submitted.

How to Avoid a Denial

  • Submit all documentation related to the service(s) billed
  • Ensure that results submitted are for the date(s) of service billed, correct beneficiary and specific service billed

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 JJ TPE Probe 1 will advance to JJ Probe 2 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