Home Health & Hospice Week

Will Sept. 1 be the kickoff date?

Get ready for a lot more scrutiny of your PDGM claims — and soon.

On Aug. 12, the Centers for Medicare & Medicaid Services announced the resumption of the Targeted Probe & Educate medical review program. “CMS is restarting the Targeted Probe and Educate (TPE) program to help educate providers and reduce future denials and appeals,” CMS says in its MLN Connects newsletter from that date.” If your Medicare Administrative Contractor audits you, take advantage of the TPE education, and get up to 3 rounds of educational claim review to help you bill accurately.”

Background: CMS began TPE on a more limited basis in late 2017, after its Probe & Educate program ran before that. When COVID-19 hit, CMS said in a Frequently Asked Question set issued in March 2020 that “no additional documentation requests will be issued for the duration of the [Public Health Emergency] for the COVID-19 pandemic” (see Eli’s HCW, Vol. XXIX, No. 12-13). Then CMS quietly restarted regular prepayment medical review in August 2020 (see Eli’s HCW, Vol. XXIX, No. 27) and post-payment review in June 2021 (see Eli’s HCW, Vol. XXX, No. 21).

CMS has yet to release any TPE details beyond those two sentences, so the scope of the program remains unclear. “TPE is a mystery right now,” notes reimbursement expert M. Aaron Little with BKD in Springfield, Missouri. No additional information has been forthcoming from either the HHH Medicare Administrative Contractors or CMS as of press time.

Exception: One BKD client did get a “cryptic” letter from MAC National Government Services, about a TPE session from before the COVID-19 PHE that was closed, Little shares.

The return of TPE before the PHE ends shouldn’t be a surprise. CMS also brought back the Review Choice Demonstration, after originally saying it would halt the program for the PHE’s duration.

“There is a pent-up demand from the MACs to conduct these reviews,” judges Joe Osentoski with Gateway Home Health Coding & Consulting in Madison Heights, Michigan. Outside RCD, home health and hospice claims haven’t seen much MAC review. And “there has been a lower amount of review conducted on postpayment pre-Public Health Emergency (PHE) claims by all three MACs,” Osentoski points out.

Osentoski “can’t think that the MACs would leave that amount of records unscrutinized,” he tells AAPC.

When TPE does hit, it’s going to weigh down home health and hospice agencies decidedly, experts forecast.

“With such a significant uptick in COVID cases now and predicted to be worse this fall, amid the continuing staffing shortages, I do not understand why CMS chose this time to resume TPE,” says Katie Wehri with the National Association for Home Care & Hospice. “It may be a substantial burden for those agencies having to respond to TPE record requests,” Wehri emphasizes.

“It would be great if the deadline could be extended,” Wehri adds.

Timeline: But agencies shouldn’t hold their breath for that. Even though the details aren’t yet out, the onset of “full TPE … will be faster than happened when CMS allowed agency-focused postpayment reviews to resume last August, since this is more a return to ‘normalcy’ of home health medical review,” Osentoski predicts.

The letter the BKD client received from NGS notes that past TPE review doesn’t exclude the agency from future TPE, and that “it is possible you will be selected for Round One TPE review activity effective 9/1/2021.” But NGS has no other information confirming that date on its website, Little notes.

Take These 3 Steps To Prep For TPE’s Return

With TPE’s quick resumption a seeming inevitability, smart agencies will consider this advice from the experts to make sure they are ready for the scrutiny:

1. Look to MA for clues on target areas. “Medicare Advantage reviews never stopped during the PHE and have pivoted to the new PDGM payment model when assessing claims under review,” Osentoski points out. “I believe that the MACs will follow suit.”

Popular targets on Patient-Driven Groupings Model claims have been “coding, diagnosis selection, and OASIS ADL item completion,” Osentoski shares. Those new areas will go along with the old favorites of face-to-face encounters and therapy reassessment issues, he expects.

2. Hold reviewers to waivers. Resumption of TPE “now brings into play the full weight of medical reviews to claims submitted during the PHE, and that may have used some of the 1135 PHE Waivers,” Osentoski highlights. “Any results from the MACs should be carefully checked to see they have allowed any waivers used by the agency,” he advises.

Such waivers could include those addressing face-toface encounters via telehealth, home health orders from non-physician practitioners, and defining homebound as having a condition that may make the patient more susceptible to contracting COVID-19, experts note.

3. Stay tuned. NAHC’s Wehri expects MACs to post TPE information to their websites very soon, she says. Keep an eye out for such info from your contractor.

Note: See the brief announcement at www.cms.gov/files/document/2021-08-12-mlnc.pdf. More TPE information, including a link to a question-and-answer set with 2019 program stats, is at www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE.