CMS Targeted Probe and Educate (TPE) Audits

Thursday, April 18, 2019 | Nicole Knight

The TPE program is designed to help providers and suppliers reduce claim denials and appeals through one-on-one assistance. Medicare Administrative Contractors (MACs) utilize data analysis to identify providers and suppliers who have high claim error rates or unusual billing practices and items and services that have a high national error rate or financial risks to Medicare. Providers are notified via letter outlining the reason for selection, overview of the process and contact information. Initially a span of 20-40 pre- or post-payment claim samples are selected for review with each round. The notification and additional documentation request (ADR) letter or system notification will indicate if the sample is pre-payment or post-payment.

After the second round, if a provider still has high improper rates, it will undergo a third probe with another 20-40 claims for review and education. MACs are supposed to educate providers on how to avoid some of the same mistakes seen in their claims. If the third round still produces continued improper rates, CMS can take additional steps, like requesting a recovery audit review, 100% prepay review, extrapolation and more.  And, obviously, you don’t want any of these!

Education will be offered to the provider throughout the TPE process. Additionally, at the end of each "round of reviews," you will receive notification in writing of the results of the claim reviews and the MAC will provide education on the potential errors identified. Providers with a moderate or major error classification will receive an offer for one-on-one education related to the specific errors identified. The goal is for providers to learn from the education and improve their claim review results in the next "round of reviews." The goal is to achieve no errors or a minor error classification.

Some of the most common claim errors are:

  1. The signature of the certifying provider was not included
  2. Documentation does not meet medical necessity

What Can You Do?

  1. Respond timely to TPE requests.
  2. Perform internal and external audits of targeted services on a routine basis.
  3. Provide ongoing education and feedback to physicians, APPs and staff.
  4. Review your EHR workflow to insure you are capturing all of the necessary components of documentation and signature requirements.
  5. Benchmark your E&M levels with the MedAxiom's Risk vs Opportunity Calculator
  6. Ensure you are documenting, capturing and billing comorbidities that impact decision making and patient care. This is essential to presenting an accurate clinical picture.

The issue is not if you are going to get audited but when. The essence of these reviews is the medical necessity of the service provided for the code billed. High level Evaluation and Management (E&M) Services continue to be a part of the probe audits for Cardiovascular services. At the end of the day, documentation that defines the patient’s presenting problems, comorbidities, differential diagnosis, treatment and risk is essential in supporting the medical necessity of the services provided. In addition, your risk adjustment factor depends on complete and accurate reporting. CMS requires that a qualified healthcare provider identify all chronic conditions and severe diagnoses for each patient, to substantiate a “base year” health profile for those individuals. Documentation in the medical record must support the presence of the condition and indicate the provider’s assessment and plan for management of the condition. This must occur at least once each calendar year for CMS to recognize that the individual continues to have the condition. This information is used to predict costs in the following year.




Illustrator: Lee Sauer

About the Author
Nicole Knight

Nicole Knight, LPN, CPC, CCS-P, ACS-CA, is Vice President, Revenue Cycle Solutions and Consulting at MedAxiom. Her decades of hands-on health care experience includes cardiology and neurology practice operations, clinical management, business office management, and consulting for coding and compliance. Nicole maintains her LPN licensure in Louisiana and Florida. She is a member of the American Academy of Professional Coders and the American Health Information Management Association. She received her Advanced Coding Certification with the Board of Medical Specialty Coding. Nicole is a certified AHIMA ICD-10-CM Trainer and completed a Lean Sigma Healthcare training course at Johns Hopkins University. She also serves on the Physician Practice Council for AHIMA.

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