Pulmonology Coding Alert

Learn from your MAC how to improve your billing.

In August 2021, the Centers for Medicare & Medicaid Services (CMS) resumed their Targeted Probe and Educate (TPE) program. CMS temporarily paused the reviews during the COVID-19 Public Health Emergency (PHE) in March 2020.

The goal of the TPE program is to educate providers, so Medicare billing claims are compliant and receive proper reimbursement. Read on to be aware of what to expect should your practice receive a Notice of Review from CMS.

Understand the Goal of the TPE Program

Picture this — imagine you’re a pitcher standing on the mound in a big baseball game and you’re having difficulty throwing strikes. Would you make better adjustments if the coach simply yelled to you from the dugout to throw better pitches? Probably not. You’ll be able to make the necessary tweaks to throw strikes when the coach comes out to the mound to deliver one-on-one advice.

The same can be said about handling complicated Medicare claims. If you’re submitting claim after claim and receiving no feedback on any possible errors until your practice receives an audit letter in the mail, then you might not make the right adjustments to get your practice compliant. The CMS TPE program plays the role of the coach coming out to the mound for a chat.

“Their whole goal is education. They’re going to make sure those providers that have a high error rate on their claims, they’re going to target those for education,” says Kathy Rowland, BSN, RN, CPC, CPC-I, CEMC, CHC, of Integrity Compliance LLC in Franklin, Tennessee. The TPE program aims to help you improve your Medicare claims quickly; and through audits, education, and one-on-one visits, they help your practice achieve compliance.

Correct Medicare Billing Claims Through Education

Most providers will never need TPE if your practice’s claims are compliant with Medicare policy. However, if you do receive the Notice of Review from the TPE program, you should take full advantage of the process to improve your claims going forward to ensure your practice can continue to bill Medicare.

The TPE program is designed to help your practice’s billing get on the right track. Medicare Administrative Contractors (MACs) use data analysis to identify providers and suppliers with high claim error rates or unusual billing. MACs also look to identify items and services with high national error rates and that could be a financial risk to Medicare. Additionally, MACs may find practices that need further education. “They have providers that have claims that are not compliant that can be shown needing TPE,” Rowland says.

What constitutes an error in the eyes of the MACs? Some of the most common claim errors include:

• Not including the signature of the certifying physician;
• Documentation doesn’t meet medical necessity;
• Encounter notes didn’t support all elements of eligibility; and
• Missing or incomplete initial certifications or recertification.

Many of these errors, such as the missing physician’s signature, are easily correctable. However, if the MAC reviews a sample of your claims and feels the errors are enough to warrant intervention, they’ll engage you in a one-on-one education session.

Don’t Delay in Responding to ADRs

If you receive a letter from your MAC stating you’re chosen for the TPE program, it’s important to understand what happens next. You should comply with the program’s requirements and deadlines, as well as understand the possible consequences of a review. “A TPE review can take months or years to resolve and can have devastating impacts on a provider’s business, up to and including revocation of Medicare billing privileges and placement on the CMS Preclusion List,” notes Royal Oak, Michigan, law firm Wachler & Associates, P.C. in a blog post (URL: www.wachlerblog.com/1503-2/).

Your MAC will request 20-40 claims and send Additional Documentation Requests (ADR) to review. Your provider will have 45 days to respond to the ADRs, and after the documentation is submitted, the MAC will provide one-on-one education to your provider. Following that session, the MAC will detail their findings and issue a letter. If the review finds a high number of denied claims, the MAC will request another sample of claims to review and schedule a second education session. If the MAC discovers a high number of denials once again, they will proceed to a third round of TPE.

Following each education session, you’ll have at least 45 days to adjust and improve your claims process. If your claims are compliant, then your practice won’t face a review for at least one year.

Most participants in the TPE program see increased accuracy in their claims, but there is a chance of multiple rounds of education sessions to ensure success. If problems persist after three rounds of education sessions, then your practice will be referred to CMS for the next steps in the process. According to CMS, the next steps “may include 100 percent prepay review, extrapolation, referral to a Recovery Auditor, or other action” (URL: www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE).