Targeted Probe and Educate Progress Update: DRG 682/683 - Renal Failure

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 JJ Probe 1 TPE review. Current JJ Probe 1 DRG 682–683 Renal Failure TPE Results are as follows:

DRG 682–683 Renal Failure

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

Number of Providers with Edit Effectiveness PerformedProviders Compliant Completed/Removed After Probe 1 Edits Providers Non-Compliant Progressing to TPE Probe 2Providers Removed from Probe 1 for Other Reasons

12

12

0

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 PerformedProviders Compliant Completed/Removed After Probe 1 EditProviders Non-Compliant Progressing to TPE Probe 2Providers Removed After Probe 1 for Other ReasonsOverall Charge Denial Rate Per State Probe 1
Alabama

5

5

0

0

2%

Georgia

3

3

0

0

1%

Tennessee

4

4

0

0

1%

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 Renal Failure

Top 3 Denial Reasons January 2, 2018, to February 28, 2020, Probe 1

  1. 5CHGE — DRG Upcode/Downcode
  2. 56900- Auto Deny — Requested Records Not Submitted Timely
  3. 5D199/5H199 — Billing Error

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

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 of 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

5D199/5H199 — Billing Error

Reason for Denial
The services billed were not covered. According to documentation in the medical record, the hospital has billed items and/or services in error. The hospital may not charge the beneficiary for items and/or services that were billed in error.

How to Avoid a Denial
To avoid future denials for this reason:

  • Check all bills for accuracy prior to submitting to Medicare
  • Ensure that the documentation submitted, in response to the ADR, corresponds with the date that the service/diagnostic test was rendered, and the dates of 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 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