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Probe Audits: Is Your Practice a Target?

Wednesday, July 3, 2019 9:00 AM

Billing, Coding & Compliance

Written by: E. Ann Rose

E. Ann Rose
Former Senior Consultant

Mistakes on Medicare claims can result in improper payment, delays in reimbursement, or no reimbursement. To mitigate this, the Centers for Medicare & Medicaid Services (CMS) conduct probe audits. When choosing candidates for probe audits, Medicare Administrative Contractors (MACs) focus on providers who have the highest claim denial rates or unusual billing practices from their peers. 

Historically, MACs would review documentation in an attempt to reduce the number of improper payments made by CMS. In recent years, CMS has shifted its focus from simply correcting Medicare claims errors to educating providers on how to prevent them. In that vein, CMS has implemented a Targeted Probe and Educate (TPE) program, in which MACs teach specific providers proper billing and coding procedures based on mistakes they’ve uncovered during the review process. By educating providers, CMS believes it can reduce claim errors, denials, and eventually the number of necessary probe audits.

The TPE Process

A TPE audit consists of up to three rounds. During each round (or probe), the MAC reviews 20 to 40 claims per provider, per item or per service. If a provider has multiple National Provider Identifiers (NPIs), each NPI could be subject to a TPE review. Moreover, when multiple items of service are billed, each time/service could be subject to a separate probe.

After each round, providers receive a letter detailing the results of their review and are offered an individualized education session — usually held via teleconference or webinar — to learn how to avoid repeat errors. This continuing education is offered in addition to instruction given during a round to fix simple errors.  

Providers found to have the highest improper payment rates in their reviewed claims during the initial round must submit a second round of 20-40 claims. If a third round still produces improper rates, practices may face extrapolation or referral to a Zone Program Integrity Contractor (ZPIC) — a fate that should be avoided at all costs. So, if faced with a TPE audit, try to minimize errors in the first round.

Hot Audit Topics

Now that you have some background on how the TPE process works, you can understand why it’s important to monitor areas that are more prone to analysis. Stay abreast of what issues are being audited (and when) by regularly checking your MAC website. To aid you, I’ve listed some common TPE audit topics below.

  • Eye exams (92002-92014). TPE auditors have been trained to audit eye codes (92002 and 92014) based on documentation of (A) all 12 elements for a comprehensive exam and (B) 11 elements or less for an intermediate exam. We recommend that our clients document at least 2-3 elements for an intermediate exam, and you may want to encourage your doctors to do the same.
  • Signature of certifying physician. Physician signatures must be legible — even on operative reports. If electronic health records are used, the certifying physician must secure (i.e., lock) his or her signature before leaving the EHR system.
  • Medical necessity. Make sure your documentation meets medical necessity and correct diagnosis codes are being reported for the problems/conditions identified in the patient chart. This will help prevent high denial rates, which can trigger a TPE audit.
  • Drugs and biologicals. For ophthalmology, this includes Botox, J0585; Avastin (if your MAC requires you to bill J9035); and Lucentis, J2778. Documentation must include the physician’s order for date(s) of service when medication(s) were administered, including the medication's name, dosage, frequency, and method of administration. When applicable, documentation must also support the number of drugs or biologicals discarded for each beneficiary.

Save Your Practice from Scrutiny

Being proactive with Medicare billing and documentation requirements can help reduce the risk of your practice being targeted for a TPE audit. Make it a best practice to regularly (1) run reports that help identify aberrant billing and denial patterns and (2) conduct internal and external audits to check for outliers. While it is commendable that CMS has chosen to educate providers on claim errors, it’s best to educate yourself on what to look out for so you can avoid a TPE audit entirely.

Need Help? We conduct medical record audits for ophthalmic practices and ambulatory surgery centers to assess the extent of compliance with Medicare rules and regulations. Visit our Billing, Coding, and Compliance page or contact us to learn more.

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