Targeted Probe and Educate Progress Update: JJ Part A Inpatient Rehabilitation Facility (IRF) A0604-D0604

The Centers for Medicare & Medicaid Services (CMS) Change Request 10249 (PDF, 241.88 KB) implemented the Targeted Probe and 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 JJ Probe 1 TPE review. Current JJ Probe 1 Inpatient Rehabilitation Facilities (IRF) A0604–D0604 TPE Results are as follows:

Inpatient Rehabilitation Facility (IRF) A0604–D0604

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

Number of Providers with Edit Effectiveness Performed Probe 1
 
Probe 1 Providers Compliant Completed/Removed After Probe 1Providers Non-Compliant Progressing to TPE Probe 2Providers Non-Compliant/Removed for Other Reason

18

0

18

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

18

0

18

0

51%

Georgia

0

0

0

0

0%

Tennessee

0

0

0

0

0%

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%

IRF A0604–D0604

Denial Reasons

  1. 5J504/5K504 — Need for Services Not Medically and Reasonably Necessary
  2. 56900 — Auto Deny — Requested Records Not Submitted Timely 
  3. 5CHGE — DRG Upcode/Downcode
  4. 5J506 — Incomplete Inpatient Rehabilitation Facility (IRF) Patient Assessment Instrument (PAI)


 
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 date(s) of service billed such as physician progress notes, physical examinations, assessments, diagnostic test results, laboratory test results, history and physical, nurse’s notes, consultations, surgical procedures, physician orders, 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

56900 — Auto Deny — Requested Records Not Submitted Timely 

Reason for Denial

The services billed were not covered because the claim was not submitted or not submitted timely in response to an Additional Documentation Request (ADR). When an ADR is generated, the provider has 45 days from the date the ADR was generated to respond with medical records. In accordance with CMS instructions, if the documentation needed to make a medical review determination is not received within 45 days from the date of the documentation request, Palmetto GBA will make a medical review determination based on the available medical documentation. If the claim is denied, payment will be denied, or an overpayment will be collected.

How to Avoid a Denial

  • 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 ADRs, 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

5CHGE – DRG Upcode/Downcode

Reason for Denial

The services billed were paid at a higher/lower payment level based on medical review of the records submitted.

How to Avoid a Denial
Under the Prospective Payment System (PPS), Medicare reimbursement rates are based on the patient’s health condition and care needs.

  • Submit orders to cover the procedures billed
  • Submit all documentation related to the services rendered

5J506/5K506 – Incomplete Inpatient Rehabilitation Facility (IRF) Patient Assessment Instrument (PAI)

Reason for Denial
Documentation submitted did not include IRF PAI assessment and/or the IRF PAI assessment submitted was not authenticated.

How to Avoid a Denial
To avoid denials for this reason, the IRF-PAI must be submitted with the medical record of the patient. The information in the IRF-PAI must be the same as the information in the patient’s medical record from the IRF. The IRF-PAI must be signed by any staff member of the IRF facility. It is preferable each person filling out the IRF-PAI sign it as they complete their portion. However, if the IRF-PAI is signed by one person before the claim is billed to Medicare it will be accepted. If a signed copy of the IRF-PAI is not submitted with the claim the claim will be denied.

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