Joe Osentoski, BAS, RN-BC ADR and Appeals Specialist Gateway Home Health Coding & Consulting LLC
Palmetto GBA (PGBA), the Jurisdiction M Medicare Administrative Contractor (MAC) PGBA TPE as well as CGS Administrators, the Jurisdiction 15 MAC CGS Update have posted updates to their home health Targeted Probe and Educate (TPE) process. The PGBA results cover probes processed October 1, 2017 through January 31, 2020. The CGS results cover probes completed October 1, 2017 through December 31, 2019. National Government Services—the MAC for Jurisdictions K and 6—continues to not post any summaries of TPE progress.
Since the dates encompassed within each Progress report vary, it makes comparisons of one MAC findings to the other very difficult. The amount of information and how it is presented for each MAC also complicates making ongoing comparisons on what progress may be made complicated, but some general trends can be gleaned from the results. For PGBA, their Findings is a moving number, where they add in new results but use the same starting date of October 1, 2017 while adding in an additional three months of review results. Since the last results posted by PGBA that ran through results of October 2, 2019, it looks like:
Number of Providers with Edit Effectiveness Performed Probe 1 is up 100 agencies. (1751 from 1651)
Providers Compliant Completed/Removed After Probe 1 is up 27 agencies (763 from 736)
Providers Non-Compliant Progressing to TPE Probe 2 is down 51 agencies (862 from 913)
Providers Removed for Other Reason is down 58 agencies (816 from 913)
Number of Providers with Edit Effectiveness Performed Probe 2 is up 121 agencies (235 from 121)
Providers Compliant Completed/Removed After Probe 2 is up 53 agencies (122 from 69)
Providers Non-Compliant Progressing to TPE Probe 3 is up 60 agencies (113 from 52)
A conclusion from this is that the number of agencies non-compliant (achieving a 20% or less charge denial rate from the probe) is essentially static, but slightly worse. This means that since the start of TPE, agencies have not been able to respond to the review and get off of the probe process, but instead have progressed at a consistent rate to further review activity. This is in the range of 40-50% failure rate. The Top 5 Denial Reasons are also essentially unchanged. Face-to-face encounter deficits account for nearly half of denials issued. The biggest change was an increase in the frequency of denials issued for lack of physician order for ordered frequency. This moved up to the number three denial reason from the prior result number 5. Other than that, the technical denials are still the primary reason for claim denials, and since these requirements did not change under the newly implemented Patient-Driven Groupings Model (PDGM) these should continue to drive denials of reviewed claims. The CGS Administrator MAC results break their findings into more detail by listing them under each TPE Edit currently in place. Only two of the edits listed have a significant number of results to review. The largest is Eligibility and Medical Necessity. Here it seems that CGS is behind PGBA in the progress of their reviews, with only 2 Round 3 probes completed (and one of the two agencies found compliant). The probe Round 2 failure rate remains high at 118 of 205 (58%) failing and proceeding into a probe Round 3 review. The 19 home health agencies that did not respond to this edit did not help themselves since this is an automatic failure of the probe. The other CGS edit with numbers is the No Response to ADR edit. 33 agencies were subject to this probe, with 6 not responding at all, and 14 of 33 (42%) who did respond failing to meet the CGS TPE threshold of 15% or less charge denial rate. There is still no excuse for a TPE Probe non-response. The prior CGS TPE Update was on 10/31/19 CGS TPE Prior. Looking back at that it appears that the number of NEW probes is essentially stagnant, with current MAC activity focusing on the continuation into Round 2 and pending Round 3. (The number of Round 1 probes for this Edit remained steady at 388 agencies). The CGS Top Denial Reasons remain the same, in the same order, and the same percentages of total denials. As the PGBA these are concentrated on technical denial areas as well as items that are mostly in effect under PDGM. The exception is the 8% denials due to Documentation did not support medical necessity of therapy services. Since therapy visits do not affect PDGM payment the same as under the prior Prospective Payment System (PPS), continuing TPE activity should see this denial reason replaced with another payment factor. So as PDGM is in full effect, and some PGBA states are also dealing with Review Choice Demonstration (IL, OH, TX; FL and NC scheduled for May 4, 2020), the basic charting and compliance requirements that have been in place before each of these are still as meaningful as ever. The physician face-to-face encounter continues to present the biggest challenge to compliant charting and billing. It’s not enough to get encounter documents timely: these must be reviewed for content, integrated into to the coding (especially now that PDGM is in effect), and checking on who completed them. Then ensure that orders are present, signed and dated before final billing is performed for the payment period at issue. By doing this nearly half of all ADR denials could be avoided. While these results from Palmetto GBA and CGS Administrators represent targeted (the “T” in TPE) agencies, other reviews reveal these issues in multiple other records. Ensure your agency Quality Assurance Performance Improvement (QAPI) program is addressing key indicators of compliance. And remember that Quality Assurance (QA) and record reviews cannot be ignored during this time of significant home health changes. Taking these actions may produce a better Targeted Probe and Educate result.