Home Health & Hospice Week

Long LOS may flag your claims for TPE review.

While operational details are still somewhat hazy, more information is emerging about the relaunched Targeted Probe and Educate medical review program. That includes the topics targeted for TPE review.

CGS

HHH Medicare Administrative Contractor CGS has the longest list of TPE topics. For HHAs, they include:

• Home Health Eligibility and Medical Necessity
• LOS with Hypertension (length of stay greater than 120 days)
• No response to Additional Development Requests
•  Low Visit Utilization (5 visits in a 60-day episode)
• LOS > 120 Days
• LOS > 180 Days
• New Providers (“relatively new” providers that have submitted at least 50 claims)

For hospices, CGS lists these TPE topics:

• LOS with Non-Oncologic Diagnosis (greater than 720 days)
• LOS in long-term care facility, nursing facility, or skilled nursing facility (greater than 180 days)
• General Inpatient Care greater than 7 days
• LOS > 180 Days
• LOS > 120 Days
• New Providers (“relatively new” providers that have submitted at least 50 claims)

NGS

On Sept. 6, HHH MAC National Government Services announced one home health topic (Home Health Medical Necessity) and one hospice topic (Length of Stay Over 730 Days)

Palmetto GBA

On Aug. 25, HHH MAC Palmetto GBA announced one home health topic (Home Health Services for Eligibility and Medical Necessity) and one hospice topic (General Inpatient Care). Palmetto shares its home health topic with both MACs and its hospice topic with CGS.