Home Health & Hospice Week

Add another wrinkle to the already confusing Probe & Educate mandate.

The burden of Medicare’s Probe & Educate medical review campaign focused face-to-face physician encounters may be heavy — but not as heavy as it first appears to some agencies.

Under the P&E program, HHH Medicare Administrative Contractors are supposed to review up to five claims from each home health agency in the nation (see Eli’s HCW, Vol. XXIV, No. 40).

Problem: Some home health agencies are seeing a lot more than five claims hit by the edit. “Due to system limitations, it is likely that for some providers more than five of your claims will be selected and generate a MR ADR and will suspend in status/location S B6001 during a nightly system cycle,” MAC CGS admits on its website.

Solution: “CGS will work to release claims in S B6001 that are in excess of the five claims,” the MAC says. “Therefore, it is important that providers wait 24-48 hours before identifying claims that remain in status/location S B6001 before responding to MR ADRs.”

How will you know which claims are affected by the Probe & Educate edit? Check the claim for P&E reason code 5013W, CGS instructs. “If your claim includes the 5013W reason code edit, wait 24-48 hours before responding,” the MAC says. “If the claim was in excess of the five claims, CGS will move the claim to continue processing, and the claim will no longer appear in status/location S B6001.”

But “if the secondary reason code is a code other than the probe and education code 5013W, providers should proceed and submit the requested documentation without waiting 24-48 hours,” CGS directs.