Medicare Administrative Contractors (MAC) have quietly been reviewing therapy providers under the Targeted Probe and Education (TPE) program. The results of the reviews are posted by contracts, and provide general insight into topics, findings and implications. Novitas has completed Round 1 of targeted therapy reviews in both the JL Jurisdiction and the JH Jurisdictions is now complete. Novitas conducted the Round 1 TPE review from July – December of 2018.
Novitas therapy TPE summarized the result of the therapy TPE for the JH Jurisdiction (AR, CO, LA, MS, NM, OK, TX, Indian Health & Veteran Affairs):
Overall 65 reviews were selected for Round One Rehabilitation Services TPE review. Out of the 65 reviews, 13 will potentially be moving on to Round Two due to an insufficient sample, moderate or major error rate classification. Novitas feels these results will improve during round two due to the extensive educational efforts conducted before and during the review process. All Round One reviews have been educated on their results and Round Two of Rehabilitation Services TPE is scheduled to begin around May of 2019.
Round 1 Results: Top Denial/Partial Denial Reasons:
- Medical Necessity – Documentation was lacking evidence of a certified/re-certified plan of care by the ordering/treating practitioner.
- Number of Units – Documentation submitted for review did not support the number of units billed. Therefore, the claim was changed to reflect the appropriate number of units supported by the documentation.
- Insufficient Documentation – Insufficient documentation was provided to support the services as billed to Medicare. Novitas Medical Review makes multiple attempts to correct these error types before completion of the review.
- Billing Errors – Upon receipt of the ADR request, the provider deemed the service was billed in error to Medicare.
Do you have an audit program in place to ensure that your documentation, coding and billing is consistent with CMS regulations and guidance?