Medical Review TPE Reviews: April 2023 to March 2024 Planned Reviews

Published 09/27/2023

Railroad Medicare’s Medical Review (MR) department is currently conducting both postpayment and pre-payment Targeted Probe and Educate (TPE) reviews.

MR will mail an initial notification letter to the providers chosen for review. This letter will explain the TPE process and request a response with the name and phone number of the person who will act as the point of contact (POC) for the provider. 

An Additional Documentation Request (ADR) letter, asking for the records for a specific claim, will be sent on each claim selected for review. MR clinicians will review your claim and the additional documentation which you submit. The reason for record review is to confirm that services were rendered according to the Medicare guidelines for medical reasonableness and necessity. 

During the TPE review, your POC may be contacted by the MR reviewer. This contact will be to discuss the review findings and, in some cases, to request additional information that could support the claim. 

A Remittance Advice (RA) will be generated after MR makes a determination on the claim. The RA will explain if the claim was allowed at the level billed, allowed but at an up-coded or down-coded level, or if the claim was denied. Railroad Medicare will also determine liability for denied services. 

The table below has the CPT® codes that are under review and a link to articles on the code or service. 

April 2023 – March 2024 Planned TPE Reviews

Type of Service CPT®/HCPCS Code Code Description
Ambulance A0425 BLS/ALS mileage, per statue mile (in combination with transport codes)
Ambulance A0427 ALS1, emergency
Ambulance A0429 BLS, emergency
Ambulance A0431 Rotary wing air transport
Ambulance A0436 Rotary wing air mileage, per statute mile (in combination with air transport code)
Drugs/Biologicals J0178 Aflibercept injection
Drugs/Biologicals J0897 Denosumab Injection
Drugs/Biologicals J2778 Ranibizumab injection
Evaluation and Management 99213 Office/outpatient visit, established, (Usually 20–29 minutes time)
Evaluation and Management 99214 Office/outpatient visit, established (Usually 30–39 minutes time)
Evaluation and Management 99215 Office/outpatient visit, established, (Usually 40–54 minutes time)
Evaluation and Management 99222 Initial hospital care
Evaluation and Management 99223 Initial hospital care
Evaluation and Management 99232 Subsequent hospital care
Evaluation and Management 99233 Subsequent hospital care
Radiology 71045 X-ray exam chest 1 view
Radiology 71046 X-ray exam chest 2 views
Radiology 77080 DXA, bone density axial
Radiology R0070 Transport portable X-ray
Radiology R0075 Transport portable X-ray, multiple patients
Radiology Q0092 Set-up portable X-ray equipment

CPT® codes, descriptors and other data only are copyright 2022 American Medical Association ®. All rights reserved.

More information on the TPE process can be accessed on the CMS TPE web page Targeted Probe and Educate | CMS.

Resources on the Palmetto GBA/Railroad Website


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