A1. When performing medical review as part of Targeted Probe and Educate (TPE), Medicare Administrative Contractors (MACs) focus on specific providers/suppliers that bill a particular item or service rather than all providers/suppliers billing a particular item or service. MACs will focus only on providers/suppliers who have been identified through data analysis as being a potential risk to the Medicare trust fund and/or who vary significantly from their peers. TPE typically involves the review of 20-40 claims per provider/supplier, per item or service. This is considered a round, and the provider/supplier has a total of up to three rounds of review. After each round, providers/suppliers are offered individualized education based on the results of their reviews. Providers/suppliers are also offered individualized education during a round when errors that can be easily resolved are identified.
What is the targeted medical review threshold?
Under the targeted medical review threshold, claims will not be reviewed unless the provider meets the criteria for review. These criteria are the same criteria applied to therapy services since 2015 and established by the Medicare Access and CHIP Reauthorization Act (MACRA).
What is targeted medical review for physical therapy?
It serves as a type of checks and balances for providers who exceed the Medicare physical therapy cap. Between 2018 and 2028, the targeted medical review threshold is $3,000 for combined PT and SLP services and $3,000 for OT services. Services above $3,000 may be subject to targeted medical review.
What types of services are covered by targeted medical review?
Historically, targeted medical review applied to all services billed under Medicare Part B, including all the following settings: Home health agencies (visits provided on an outpatient basis) Rehabilitation agencies (also known as outpatient rehabilitation facilities)
What is a Medicare claim review?
A Medicare contractor may use any relevant information they deem necessary to make a prepayment or post-payment claim review determination. This includes any documentation submitted with the claim or through an additional documentation request. (See sources of Medicare requirements, listed below). Who conducts the medical reviews?
What is a Medicare medical review?
Medical reviews involve the collection and clinical review of medical records and related information to ensure that payment is made only for services that meet all Medicare coverage, coding, billing, and medical necessity requirements.
What does it mean to be medically reviewed?
Medical review is the collection of information and clinical review of medical records by physician advisors (for providers reviewing cases before submissions) or a peer review team (for payers) to ensure that payment is made only for services that meet coverage, coding, and medical necessity requirements.
What are the Medicare therapy Threshold limits for 2021?
For CY 2021 (and each calendar year until 2028 at which time it is indexed annually by the MEI), the MR threshold is $3,000 for PT and SLP services and $3,000 for OT services. The targeted MR process means that not all claims exceeding the MR threshold amount are subject to review as they once were.
What is a CMS TPE?
CMS's Targeted Probe and Educate (TPE) program is designed to help providers and suppliers reduce claim denials and appeals through one-on-one help. The goal: to help you quickly improve. Medicare Administrative Contractors (MACs) work with you, in person, to identify errors and help you correct them.
What does a medical review nurse do?
As a medical record review nurse, you perform a utilization review of the coverage a patient received and help determine the medical necessity of each treatment. Your primary task in this role is to help minimize the costs of hospitalization or other treatments while still ensuring a high level of patient care.
What is a focused medical review?
fo·cused med·i·cal as·sess·ment. (fō'kŭst med'i-kăl ă-ses'mĕnt) Physical examination of a prehospital patient that focuses on body areas and systems as indicated by the patient's chief complaint and initial assessment.
How many PT sessions will Medicare pay for?
There's no limit on how much Medicare pays for your medically necessary outpatient therapy services in one calendar year.
How often will Medicare pay for a physical exam?
En español | Medicare does not pay for the type of comprehensive exam that most people think of as a “physical.” But it does cover a one-time “Welcome to Medicare” checkup during your first year after enrolling in Part B and, later on, an annual wellness visit that is intended to keep track of your health.
How is the Medicare therapy cap calculated?
Medicare allowable charges,which includes both Medicare payments to providers and beneficiary coinsurance, are counted toward the therapy cap. In outpatient settings, Medicare will pay for 80 percent of allowable charges and the beneficiary is responsible for the remaining 20 percent of the amount.
What triggers Medicare audits?
What Triggers a Medicare Audit? A key factor that often triggers an audit is claiming reimbursement for a higher than usual frequency of services over a period of time compared to other health professionals who provide similar services.
What is a Medicare Part B TPE audit?
A TPE audit involves a maximum of three rounds of review. In each round, the MAC will review between 20–40 billing claims and medical records supporting each claim. The MAC has the discretion to determine whether the healthcare organization is compliant with CMS regulations.
Are Medicare audits random?
For example, the Medicare program is required to make random audits of 10% of all Medicare providers on an ongoing basis. An audit or investigation can result from complaints by patients about the quality or appropriateness of the care they received, or how they were billed for their care.
What is MAC in Medicare?
Medicare Administrative Contractors (MACs) work with you, in person, to identify errors and help you correct them. Many common errors are simple – such as a missing physician's signature – and are easily corrected.
Do I need TPE for Medicare?
Most providers will never need TPE. TPE is intended to increase accuracy in very specific areas. MACs use data analysis to identify: providers and suppliers who have high claim error rates or unusual billing practices, and. items and services that have high national error rates and are a financial risk to Medicare.
Why do speech pathologists use KX modifiers?
The speech-language pathologist's use of the KX modifier is an attestation to CMS that services are medically necessary and justification of the need for services above the threshold is documented in the medical record. If CMS finds that documentation does not support ...
Can a claim be reviewed under the targeted medical review threshold?
Under the targeted medical review threshold, claims will not be reviewed unless the provider meets the criteria for review. These criteria are the same criteria applied to therapy services since 2015 and established by the Medicare Access and CHIP Reauthorization Act (MACRA).
Is the GN modifier necessary for speech pathology?
are reasonable and necessary services that require the skills of the speech-language pathologist; are justified by appropriate documentation. The use of the GN modifier to identify speech-language pathology services is still required, in addition to the K X modifier.
What is medical record?
Medical record documentation is required to record pertinent facts, findings, and observations about an individual’s health history including past and present illnesses, examinations, tests, treatments, and outcomes. Find tips, tools and resources for the documentation of clinical services provided to Medicare patients.
When will MACs resume post payment reviews?
Beginning August 2020, MACs resumed post-payment reviews of items and services with dates of service before March 2020. MACs may now begin conducting post-payment medical reviews for later dates of service.
