Targeted Probe and Educate Audits Have Resumed: Are You a Target?

by Deborah Alexander, Director on October 8, 2021

medical documentation

 

On August 12, 2021, the Centers for Medicare & Medicaid Services (CMS) released an MLNConnects Newsletter announcing the resumption of the Targeted Probe and Educate (TPE) Program. No effective date was reported in the announcement, but LW Consulting, Inc. (LWCI) has seen service-specific medical reviews currently in effect listed. The medical reviews underway are impacting both Part A and Part B providers, with some common themes across several of the Medicare Administrator Contractors (MACs).

In this blog, we are going to review First Coast Service Options, Inc. (FCSO). FCSO serves as the CMS Part A and Part B MAC for Florida, Puerto Rico, and the US Virgin Islands. Currently, FCSO lists CPT codes 97110 and 97530 as active reviews for both Part A and Part B Therapy providers with some preliminary results. Current medical reviews can be found on the FCSO website.

What are some of the current FCSO TPEs and service-specific reviews in effect?

  • CPT Code 97110 for Outpatient Rehabilitation Facility – Active
  • CPT Code 97112 for Rehabilitation Services - Active
  • CPT Code 88312 for Laboratory Services – Pending
  • CPT Code J1569 Drug Injections – Active
  • CPT Codes 90832 – 90893 Psychotherapy – Active
  • CPT Code 80305 – 80307 Clinical Labs - Active

What are some of the service-specific review results posted?

Part B Medical Reviews for CPT 97110 OPT Therapy

A post-payment audit of CPT 97110 reported 2653 allowable and 1703 denied claims for a review period of August 2020 – November 2020, which is a 39% denial rate. The most common full or partial denial reasons listed were:

  1. Documentation did not support medical necessity of services provided citing:
    1. Previous responses to therapy and activities of daily living (ADL) functional limitations were not clearly indicated in measurable terms.
    2. The patient’s progress was not written in measurable terms as it related to ADLs.
  2. The documentation provided was insufficient to support the services as billed to Medicare. Multiple attempts are made to correct these error types before completion of the review citing the following:
    1. Documentation did not support the number of units billed based upon the treatment times.
    2. Documentation did not include valid certifications or delayed certifications as outlined in the LCD.
    3. Documentation did not include a certified plan of care (POC) and/or improvement or progress towards the POC.

Part A Medical Reviews for CPT 97110 and 97530 Therapy Review Findings

A post-payment audit of CPT 97110 and 97530 are underway. As of September 30, 2021, no results have been posted for CPT 97530. A results summary is present for CPT Code 97110 reporting 1091 allowable and 222 denied claims for a review period of August 2020 – November 2020, which is a 17% denial rate. The most common full or partial denial reasons listed were:

  1. Documentation did not support medical necessity of services provided citing:
    1. The documentation provided was insufficient to support the services as billed to Medicare.
    2. Documentation submitted did not contain initial evaluations for the start of treatment, 10th visit progress notes, and/or updated plans of treatment to help support medical necessity.
  2. Documentation does not meet Local Coverage Determination by lacking physician certifications or recertifications and did not include valid certifications or delayed certifications as outline in the LCD.

Look for upcoming additional blogs where we will discuss and summarize other MAC TPE Medical Reviews.

How Can LW Consulting, Inc. Help?

  • LWCI conducts clinical documentation audits that include billing and coding (ICD-10 and CPT).
  • LWCI provides audit response support, including audit response preparation, appeals, and denials management. We can also provide assistance with setting up your internal audit response process.
  • LWCI offers our documentation audit tool, ChartVerify®, which is a proprietary cloud-based auditing subscription service that allows providers to conduct documentation audits in one fast, easy format with exported reports.

 

To learn more about how LWCI can help you, set up a 15-minute discussion with one of our experts, Deborah Alexander, Director, CHC, CHPC, PMP, DPT, MED, STC, CSCS.

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Topics: Compliance, Documentation, Billing, & Coding