Tuesday, October 16, 2018

WPS – The CMS MAC for IA, IN, KS, MI, MO, and NE Announces Part B Therapy Audit Plan for Code 97110

Dan Ciolek

On October 15, WPS Government Health Administrators, the Medicare Administrative Contractor (MAC) for the J5 (Iowa, Kansas, Missouri, and Nebraska) and J8 (Indiana and Michigan) jurisdictions announced a new Targeted Probe and Educate (TPE) Topic:  Outpatient Therapy (CPT Code 97110).  The audit will include a review of medical necessity, correct billing of timed codes and all other therapy codes provided under same plan of care.  Several documentation and other therapy coverage resources are provided on this page.  

Per the WPS website, “CMS has authorized WPS Government Health Administrators (GHA) to conduct the Targeted Probe and Educate (TPE) review process. This is a required process for providers identified by Medical Review. The TPE review process incudes three rounds of prepayment or post-payment probe review with education. If high denial rates continue after three rounds or review, WPS GHA will refer the provider and results to CMS. CMS will determine any additional action, which may include but is not limited to extrapolation, referral to the Unified Program Integrity Contractor (UPIC), and/or referral to the Recovery Audit Contractor (RAC).”
Pre WPS, Providers/Suppliers can expect:
  • WPS GHA will notify providers/suppliers in writing of their selection for the topic or CPT code under review, the data reasons for selection and the review process.
  • Provider/supplier reviews will consist of up to three rounds of prepayment or post-payment TPE claim review. WPS GHA will select the topics for review and the providers to be reviewed based on our current data analysis procedures outlines in CMS Internet-Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 2.
  • WPS GHA may refer providers/suppliers to RAC or UPIC if providers do not respond to ADR requests and submit the requested documentation to WPS GHA.
  • If needed, education will be offered to the provider/supplier throughout the TPE process. Additionally, at the end of each round of claim review WPS GHA will notify the provider/supplier in writing of the results and offer education on identified errors. Providers/suppliers with high error rates will receive on offer for one-on-one education on the specific errors that were identified. The goal for providers/suppliers is to learn from the education and improve the results in the next “round” to a low error category.
  • Providers/suppliers will move to the next round of claim review if the error rate remains at a high level. Providers/suppliers with a continued high denial rate after three rounds of Targeted Probe and Educate reviews will be referred to CMS for possible for further action.
  • Once a provider/supplier has reached an acceptable error rate the provider will be removed from further review. WPS GHA will continue to routinely monitor data on that service/provider.
  • Note: Discontinuation of the review(s) may occur at any time if appropriate improvement is achieved during the review process.
Additional resources related to the TPE audit program including videos, infographics, and a Q&A document are located on the CMS Targeted Probe and Educate webpage.

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