In recent blogs, we outlined medical Medicare review strategies; probe and educate (PE); we explained Targeted Probe and Educate (TPE), Medicare’s new medical review strategy; and we offered strategies for preparing and submitting TPE documentation. In this blog, we will share tips on navigating the TPE claims review process.

Upon receipt of your TPE documentation, medical records are reviewed within 30 days of the received date. This does not mean the claim will complete processing within 30 days—only that the medical record review will be completed within that time frame.

Once documentation is received, the claim transitions from status/ location S B6001 to S M50MR for review in Direct Data Entry (DDE). It is first reviewed for administrative documentation, then medical documentation.

If at any time during the process it’s determined that documentation is missing, incomplete or insufficient, the review process will end without review of the remaining documents.

Document Review Phases – Technical and Eligibility

Generally speaking, the documentation review process includes two phases: Technical and Eligibility. A breakdown of each appears below.

Technical Review

This includes:

Beneficiary election statement (aka, notice of election)

Required elements include:

• Hospice name
• Effective date of election
• Individual’s (or representative’s as applicable) acknowledgment of full understanding of palliative rather than curative nature of hospice services
• Individual’s (or representative’s as applicable) acknowledgment that they understand certain Medicare services are waived by the election
• Identification of the attending physician and acknowledgment that the identified physician was his or her choice
• The individual’s (or representative’s as applicable) signature

All technical components of certification and recertifications

Applicable components that cover the period under review include:

• Statement(s) of prognosis of six months or less
• Narrative(s)
• F2F(s) where applicable. Remember: A 30-day period under review may have two benefit periods
• Remittance of certifications to cover both benefit periods
• For longer periods under review, there may be more certifications

Plan(s) of care

Components include:

• Initial plan of care developed before services were provided, so long as the period under review includes readmission
• Every 15 days at a minimum
• Send all plans of care which cover the period under review
• All documents that make up the plan of care
• Signatures or other documentation which show involvement of the Interdisciplinary Group (IDG)

Remember: The period under review may have more than one plan of care.

Signatures and signature dates

Signatures must be legible; if they are not, and were not signed over a printed name, the agency must include a signature log or attestation statement from the signer. Review MLN-Complying With Medicare Signature Guidelines. You can get more information on signatures and signature dates here.

Face-to-face

• The face-to-face visit should be conducted no more than 30 days prior to the start of all 60-day benefit periods and no later than the first day of that benefit.
• The nurse practitioner or certifying physician who completes a face-to-face visit must complete an attestation statement which includes the date the visit was made, as well as the practitioner’s or physician’s signature and date of attestation.
• If the certifying physician conducts the face-to-face, (s)he must attest (generally on the Certification of Terminal Illness (CTI)) that the findings of the face-to-face were used in determining eligibility.
• When a nurse practitioner or a non-certifying physician conducts the face-to-face, the attestation must include a statement that findings were communicated to certifying physician.

Note: A face-to-face visit is NOT a narrative replacing a physician narrative on the CTI.

Eligibility Review

This includes:

• Medicare coverage guidelines
• Documentation to support the services billed
• General inpatient services
• Continuous home care
• Physician notes
• Ensuring that face-to-face meets all applicable requirements

Note: Technical review must be passed first

TPE Outcomes

Once your claim is submitted, you can monitor its status in Direct Data Entry (DDE). The Medicare Administrative Contractor (MAC) has 30 days from receipt to review the claim, and the decision will be posted on the Fiscal Intermediary Standard System (FISS system).

There are three possible outcomes: payment in full (P B9997); partial payment (P B99997); and full denial (D B99997).  

Related Blogs:

Medicare Medical Review Strategies

Understanding Targeted Probe and Educate for Hospice Agencies 

Preparing and Submitting Your TPE Documentation

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