Medicare Compliance & Reimbursement

Hint: Take detailed notes to circumvent TPE reviews.

You may think with the Centers for Medicare and Medicaid Services onslaught of administrative rollbacks that concise documentation isn’t as important as it once was to the feds — but, you’d be wrong. Medicare claims review programs like Targeted Probe and Educate (TPE) consistently point to lackluster documentation as the primary reason for denials.

Whether you’re in the midst of a TPE review and want to avoid moving onto the next probe round or whether you just want to see if you’re submitting claims with the right documentation, it’s a good idea to know what’s on the Medicare Administrative Contractors (MACs) radar.

Reminder: TPE is a Medicare claims review process performed exclusively by the MACs. TPE targets at-risk providers and consists of three rounds of review, in which 20 to 40 claims per round are selected for an audit. The MACs decide how many claims a practice must furnish and when to send them.

Practices are alerted by letter; however, audit start dates and providers’ end dates for TPE rounds will vary due to when they receive this letter. The MACs allow 45 days to respond with Additional Development Requests (ADRs). But, you should respond in 30 because “claims will deny on day 46 if the records are not received,” advises Part B MAC NGS Medicare.

Consider these three documentation questions for codes frequently found on the MACs’ TPE hitlists.

Question 1: What key components must be evident in your documentation to use the higher-level subsequent hospital care code 99233 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components...)?

Question 2: What kind of provisions must your notes display to back up the use of critical care code 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes ...)?

Question 3: How would your documentation highlight the differences between 99490 (Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month ...) and 99491 (Chronic care management services, provided personally by a physician or other qualified healthcare professional, at least 30 minutes of physician or other qualified healthcare professional time, per calendar month …) and determine the correct code choice?

Check your answers.