Improve Provider Documentation Through TPE Audits

Preventing denials starts with provider evaluation and education.

The Centers for Medicare & Medicaid Services (CMS) has authorized its Medicare Administrative Contractors (MACs) to conduct Targeted Probe and Educate (TPE) reviews of Medicare claims. The TPE review process includes three rounds of prepayment probe review with education. If a provider continues to have high denial rates after the first three rounds, MACs will refer them to CMS. At that point, CMS will determine additional action, which may include extrapolation and referral to a recovery auditor.

Key elements of this process include:

• MACs will review providers and services based on existing data analysis.
• MACs will notify providers in writing of the claims being reviewed, reasons for selection, and details regarding the review process (documentation for 20-40 claims is usually requested).
• MACs may refer providers/suppliers to a recovery auditor if they do not respond to an Additional Documentation Request (ADR) letter and submit the requested documentation.
• Education will be offered to the provider throughout the TPE process, as needed. At the end of each round, MACs will provide notification in writing of the claim result findings and education on errors identified. Providers with high error rates will be offered one-on-one education related to specific errors identified. The goal is for providers to learn from the education provided and improve their results in the next round of review:
  • Providers will be moved to another round of review if error rates remain high.
  • Once a provider has reached an acceptable rate, they will be removed from review of that service; MACs will continue to monitor data on that service/provider.
• Providers with continued high denial rates after three rounds of prepayment TPE reviews will be referred to CMS for possible further action.

Providers selected for TPE review are not excluded from other medical review activities, such as automated reviews, comparative billing reports, mandated demand bill reviews, pilot review strategies, etc. Additionally, MACs will continue to work with other CMS contractors and collaborate with referrals to Quality Improvements Organizations (QIO) for concerns regarding quality care, Zone Program Integrity Contractors (ZPICs) for concerns related to potential fraud and abuse, and Recovery Audit Contractors (RACs) to evaluate vulnerability and ensure there is no duplication of reviews.

House Call Documentation Under Review

The Office of Inspector General (OIG) has had physician home visits on its work plan for evaluation of the medical necessity of services provided.

“We will determine whether Medicare payments to physicians for evaluation and management home visits were reasonable and made in accordance with Medicare requirements. Since January 2013, Medicare made $559 million in payments for physician home visits. Physicians are required to document the medical necessity of a home visit in lieu of an office or outpatient visit. Medicare will not pay for items or services that are not reasonable and necessary.”

This vital background provides a significant rationale behind the MAC TPE audit. It also allows an auditor to develop an outline of specific risks and red flags when reviewing the documentation of 20-40 claims. Risks and red flags include:

• Visits found to be not medically necessary.
  • Routine visits that do not meet state or facility requirements.
  • Routine visits that are repetitive and unnecessary.
• Billing an E/M code and minor procedure on same day.
• Cloning: Documents are considered cloned when each entry in the medical record is identical or similar to previous entries.
• Incorrect coding and place of service (POS).

Medical Necessity Elements Impact Place of Service

Documentation of medical necessity for house calls, assisted living visits, group home visits, and custodial care facility visits is captured differently than in physician offices or the hospital setting. To show medical necessity, the documentation must include a statement indicating why the visit was necessary — for example, home-limited status.

This process of obtaining information regarding reasonableness and necessity starts at intake by asking the following questions:

• Who is calling?
• Why do they need to be seen?
• Where do they live? During patient intake, it is imperative to find out where they live because POS is critical and impacts code selection.

Assign an appropriate POS code:

• POS 12 Home
• POS 13 Assisted living facility
• POS 14 Group home
• POS 33 Custodial care facility

Level Requirements for House Calls (POS 12)

Level Requirements for Assisted Living Calls (POS 13, 14, 33)

CPT® Coding Elements

Physician home visits are reported with codes from the Evaluation and Management section in CPT®. Level of service is based on the following elements:

• Chief complaint (CC)
• History of present illnesses (HPI)
• Review of systems (ROS)
• Past, family, and social history (PFSH)
• Levels of examination
• Medical decision making
• Number of diagnoses and/or management options

I recommend focusing on 1997 Documentation Guidelines for Evaluation and Management (E/M) Services for levels of examination for patients who are critically ill. These guidelines define levels of exam as follows:

Key Documentation Elements

The assessment and plan portion of house call documentation should include the following information regarding diagnoses and management options:

• Statement of clinical impression, assessment, and diagnosis. For each condition being treated, include disease status:
  • Well-controlled, improved/resolving, resolved
  • Inadequately controlled, worsening, failing
• Description of the patient’s overall health status

Keep in mind, this is not the patient’s problem list and should only contain the diagnoses managed during the encounter.

Documentation of treatment should always include:

• Kind of treatment:
  • Patient instructions
  • Therapeutic modality (physical therapy, occupational therapy, etc.)
  • Medications
  • Referrals/consultations – Specify to whom the patient is being referred (provider, specialty, etc.), where they are located, and what information is being sought.
• Date of treatment initiation
• If changes in treatment are made, document date of the change and what change is being made.

It’s important to advise physicians wanting to use time-based criteria for their E/M coding to document:

• Whether greater than 50 percent of the visit was spent on counseling and coordination of care
• Total time spent on the encounter, preferably specifying time in and time out
• Specific information covered during counseling and coordination of care

Warning: Do not bill exclusively via time-based criteria because it adds significant risk to the practice. If time is billed exclusively, the three main bullet points above must be addressed in all documentation to remain compliant and pass the scrutiny of MAC auditors.

Third Time’s a Charm

Your objectives when submitting claims for the various types of house call visits involve:

1. Determining all the appropriate CPT® codes with their respective POS codes;
2. Defining and demonstrating medical necessity and reasonableness;
3. Highlighting documentation elements to support E/M level; and
4. Minimizing practice risk through thorough documentation.

Help educate physicians on how to correctly capture code selection while developing compliant documentation for the services rendered by following these steps. By providing focused education on the parameters of TPE audits, house-call physicians can successfully pass their TPE review by the third round via demonstrating quality claims documentation.

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Sonal Patel

Sonal Patel, CPMA, CPC, CMC, is a healthcare coding and compliance consultant at the law firm of Nexsen Pruet, LLC. She has over 10 years of experience in multi-specialty healthcare coding and auditing. She provides reimbursement investigations for Parts A and B providers. Patel delivers healthcare lawyers with strategies and analyses to overturn denials with private and government payers. She is a member of the Northbrook, Ill., local chapter.

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