Medical Review TPE Reviews: October 2021 - September 2022 Planned Reviews
Palmetto GBA Railroad Medicare’s Medical Review (MR) department is conducting both postpayment and pre-payment Targeted Probe and Educate (TPE) reviews in the current year.
MR will mail an initial notification letter to the providers chosen for review. This letter will explain the TPE process and request a response with the name and phone number of the person who will act as the point-of-contact (POC) for the provider.
An Additional Documentation Request (ADR) letter, asking for the records for a specific claim, will be sent on each claim selected for review. MR clinicians will review your claim and the additional documentation which you submit. The reason for record review is to confirm that services were rendered according to the Medicare guidelines for medical reasonableness and necessity.
During the TPE review, your POC may be contacted by the MR reviewer. This contact will be to discuss the review findings and, in some cases, to request additional information that could support the claim.
A Remittance Advice (RA) will be generated after MR makes a determination on the claim. The RA will explain if the claim was allowed at the level billed, allowed but at an up-coded or down-coded level, or if the claim was denied. Railroad Medicare will also determine liability for denied services.
The table below has the CPT codes that are under review and a link to articles on the code or service.
October 2021 – September 2022 Planned TPE Reviews
|
Type of Service |
CPT/HCPCS Code |
Code Description |
|
Ambulance |
A0425 |
BLS/ALS mileage, per statue mile |
|
Ambulance |
A0426 |
ALS1, non-emergency |
|
Ambulance |
A0427 |
ALS1, emergency |
|
Ambulance |
A0428 |
BLS, non-emergency |
|
Ambulance |
A0429 |
BLS, emergency |
|
Ambulance |
A0431 |
Rotary wing air transport |
|
Ambulance |
A0436 |
Rotary wing air mileage, per statute mile |
|
Drugs/Biologicals |
J0178 |
Aflibercept injection |
|
Drugs/Biologicals |
J0897 |
Denosumab Injection |
|
Drugs/Biologicals |
J1745 |
Infliximab injection; 10mg (not biosimilar) |
|
Drugs/Biologicals |
J2778 |
Ranibizumab injection |
|
Drugs/Biologicals |
J9312 |
Rituximab injection, 10 mg |
|
Laboratory |
G0480 |
Drug test definitive, 1-7 classes |
|
Laboratory |
G0481 |
Drug test, definitive, 8-14 classes |
|
Laboratory |
G0482 |
Drug test, definitive, 15-21 classes |
|
Laboratory |
G0483 |
Drug test, definitive, 22 or more classes |
|
Laboratory |
80305 |
Drug test, presumptive; direct optical observation |
|
Laboratory |
80306 |
Drug test, presumptive; instrument-assisted |
|
Laboratory |
80307 |
Drug test, presumptive; chemistry analyzers |
|
Laboratory |
88305 |
Tissue exam by pathologist |
|
Laboratory |
88307 |
Tissue exam by pathologist |
|
Laboratory |
88309 |
Tissue exam by pathologist |
|
Laboratory |
88312 |
Special stains; group 1 |
|
Radiology |
71045 |
X-ray exam chest 1 view |
|
Radiology |
71046 |
X-ray exam chest 2 views |
|
Radiology |
77080 |
DXA, bone density axial |
|
Radiology |
R0070 |
Transport portable x-ray |
|
Radiology |
R0075 |
Transport portable x-ray, multiple patients |
|
Radiology |
Q0092 |
Set-up portable x-ray equipment |
|
Therapeutic Procedures |
97110 |
Therapeutic exercises |
|
Therapeutic Procedures |
97112 |
Neuromuscular reeducation |
|
Therapeutic Procedures |
97113 |
Aquatic therapy/exercises |
|
Therapeutic Procedures |
97116 |
Gait training therapy |
|
Therapeutic Procedures |
97140 |
Manual therapy, 1/> regions |
|
Therapeutic Procedures |
97150 |
Group therapeutic procedures |
CPT® codes, descriptors and other data only are copyright © 2020 American Medical Association. All rights reserved.
Resources on the Palmetto GBA Railroad website: