Targeted Probe and Educate Progress Update: JM Part B Ambulance A0427-A0429 Ambulance Services (Emergent)

The Centers for Medicare & Medicaid Services (CMS) Change Request 10249 (PDF, 241.88 KB) implemented the Targeted Probe and Educate (TPE) process, effective October 1, 2017. The following provides JM TPE Probe results statistics from October 1, 2017, to February 28, 2020.

Findings
Medical Review initiated Probe review edits for providers identified through data analysis demonstrating high risk for improper payment. Providers have been offered education throughout and upon completion of the Probe TPE review. Current JM Part B Probe 1 Ambulance A0427–A0429 Ambulance Services (Emergent) TPE Results are as follows:

Ambulance: A0427–A0429 — Ambulance Services (Emergent)

Probes Processed October 1, 2017, to February 28, 2020

Findings by State
Palmetto GBA’s overview of results by state, for providers who have had edit effectiveness performed, for Probe 1 TPE review from October 1, 2017, to February 28, 2020.

Risk Category
Risk Category is defined based on end of Probe 1 provider error rates. The categories are defined as:

1. NOTMN — Payer deems the information submitted does not support the medical necessity of the services billed
2. NODOC — Documentation requested for this date of service was not received or was incomplete
3. DOWNC — Payer deems the information submitted does not support this level of service; downcoded
4. BNSIG — Documentation received lacks the necessary beneficiary or authorized representative signature
5. WRONG — Documentation received contains an incorrect/incomplete/illegible patient identification or date of service

NOTMN
Payer deems the information submitted does not support the medical necessity of the services billed.

• Ensure that all documentation to support medical necessity of the service billed is submitted for review. This includes original chart notes and any diagnostic, radiological, or laboratory results.
• Verify that documentation to support the level of service billed is included. Please refer to the website at www.PalmettoGBA.com for links to applicable LCDs, NCDs and the E/M Scoresheet Tool for documentation requirements

NODOC
Documentation requested for this date of service was not received or was incomplete.

• Submit all documentation related to the services billed within 45 days of the date on the ADR letter
• Review documentation prior to submission to ensure that the documentation is complete and that all dates of service requested are included
• Include any additional information pertinent to the date of service requested to support the services billed. For example: original chart notes, diagnostic, radiological, or laboratory results
• For claims denied with a M127 or N29 code listed on the remittance advice, be sure to submit all documentation for all dates of service on that claim with a reopen/redetermination request form by fax to (803) 6992427

DOWNC
Payer deems the information submitted does not support this level of service; downcoded.

• Ensure that all documentation to support the level of service billed is submitted for review
• Verify that documentation to support the level of service billed is included. Please refer to the website at www.PalmettoGBA.com for links to applicable LCDs, NCDs and the E/M Scoresheet Tool for documentation requirements.

BNSIG
Documentation received lacks the necessary beneficiary or authorized representative signature.

• Review documentation prior to submission to ensure that the proper beneficiary or authorized representative signature is included and is legible
• For illegible signatures, clearly print or type the full name of the owner of the signature

WRONG
Documentation received contains an incorrect/incomplete/illegible patient identification or date of service.

• Review all documentation prior to submission to ensure that it is for the correct patient and date of service
• Ensure that patient identifiers are legible and complete
• Ensure that the complete date of service is clearly and legibly noted on all documentation
• Prior to billing claims, review the information to determine that the correct patient identifier and the correct date of service are listed in the appropriate field

Education
Providers are offered an individualized education session where each claim denial will be discussed, and any questions will be answered. Palmetto GBA offers a variety of methods for provider education such as webinar sessions, web-based presentations, or teleconferences. Other education methods may also be available.

Next Steps
Providers found to be non-compliant (major risk category/denial rate of 21–100%) at the completion of TPE Probe 1 will advance to Probe 2 of TPE at least 45 days from completion of the 1:1 post probe education call date. Palmetto GBA offers education at any time for providers. Providers do not have to be identified for TPE to request education.

References

• CMS Targeted Probe and Educate (TPE) web page
• Change Request 10249 (PDF, 241.88 KB)