The federal Targeted Probe and Educate program, commonly known as TPE, is not new. But as Medicare medical review activity continues to focus on accuracy, documentation support, medical necessity, and payment integrity, it is a topic that clinical documentation integrity (CDI) departments and coding professionals need to understand more deeply.
TPE is often viewed as a billing, compliance, denials, or utilization review (UR) issue. And while all those areas are involved, CDI and coding should not be excluded from the conversation. The documentation and coding decisions made before the claim is submitted often become the exact same issues reviewed later when a provider, supplier, hospital, or service is selected for medical review.
That makes TPE a documentation integrity issue.
The Centers for Medicare & Medicaid Services (CMS) describes TPE as a program designed to help providers and suppliers reduce claim denials and appeals through one-on-one education. Medicare Administrative Contractors (MACs) use data analysis to identify providers and suppliers with high claim error rates, unusual billing practices, or items and services with high national error rates that pose financial risk to Medicare. Most providers will never need TPE, but for those selected, the process focuses on specific areas where accuracy can be improved.
For CDI and coding teams, the important point is this: TPE is not random education. It is targeted, data-driven, and based on whether claims and the supporting medical records align.
Traditional TPE generally begins when the provider receives a letter from the MAC. The MAC reviews a sample of claims and supporting medical records, typically 20 to 40 claims per traditional round. If some claims are denied, the provider is invited to participate in one-on-one education. The provider is then given at least 45 days to make changes and improve before another round of claims is reviewed. This process may occur for up to three rounds.
CMS also notes that there are variations to the traditional 20-to-40 claim model. For example, the Low Biller Probe and Educate program focuses on providers and suppliers with lower claim volumes, and may involve fewer than 20 claims per round, up to three rounds, with education continuing after each round.
If the provider becomes compliant, CMS indicates that the provider generally will not be reviewed again for at least one year on the selected topic. However, MACs may conduct additional review if significant changes in provider billing are detected. If accuracy does not improve after three rounds of education, the provider may be referred to CMS for next steps. Those next steps may include 100-percent prepayment review, extrapolation, referral to a Recovery Auditor (RA), or other action.
That is where CDI, coding, and UR need to pay close attention.
TPE can affect both inpatient and outpatient areas, which is why this topic matters to inpatient CDI, outpatient CDI, coding, UR, compliance, and revenue cycle teams.
For inpatient cases, TPE risk may involve whether the medical record supports the inpatient admission, continued hospitalization, medical necessity of services, certification requirements, procedures, diagnoses, treatment intensity, or level of care billed. These cases often require close CDI and UR alignment, because the record must support not only what was coded, but also why the patient required hospital-level care, and why the services billed were reasonable and necessary.
For outpatient cases, TPE risk may look different, but it is just as important. Outpatient reviews may focus on whether the encounter documentation supports the service billed, whether all required elements are present, whether the diagnosis supports medical necessity; whether orders, signatures, or certifications are complete; whether procedures or therapies meet coverage requirements; or whether the frequency and intensity of services are supported. Outpatient CDI and coding teams are increasingly important in this space, because outpatient documentation must support diagnosis reporting, risk adjustment, medical necessity, coverage, and each service billed.
This distinction matters because inpatient and outpatient teams may see TPE risk through different lenses. Inpatient CDI may focus on acuity, severity of illness, treatment intensity, admission rationale, and status integrity. Outpatient CDI may focus on diagnosis specificity, chronic disease burden, risk adjustment, encounter support, procedure documentation, and medical necessity for ordered or performed services. Coding may determine whether the available documentation can support the final claim. UR may see whether the service, setting, level of care, or continued stay is defensible under Medicare requirements.
The common thread is the same: the claim must be supported by the medical record.
TPE is not just about whether the claim was submitted correctly. It is about whether the medical record supports what was billed, coded, ordered, certified, or reported. CMS identifies common claim errors, including missing physician signatures, encounter notes lacking all required elements of eligibility, documentation not meeting medical necessity, and missing or incomplete certifications or recertifications.
Those examples may sound administrative, on the surface, but each has a documentation integrity component.
For CDI professionals, the connection is clear. We are trained to evaluate whether provider documentation accurately reflects the patient’s condition, acuity, severity of illness, risk, treatment, and clinical rationale. We query when clarification is needed. We educate providers when documentation lacks specificity or fails to reflect the clinical picture fully.
For coders, the connection is equally important. Coding cannot create support that is not present in the record. Coding accuracy depends on complete, consistent, and compliant provider documentation. When a claim is reviewed under TPE, the issue may not be limited to whether the code selected was technically correct; the question may be whether the medical record supports the service, diagnosis, procedure, level of care, certification, or medical necessity associated with that claim.
This is why CDI and coding teams need to understand TPE before an organization is selected, not after.
The strongest response to TPE is not built during the education session, but rather into the medical record, in real time, before the claim is submitted.
This is also where utilization review becomes an essential partner.
UR teams understand medical-necessity requirements, admission status, continued-stay review, payer rules, Medicare requirements, Medicare Advantage (MA) utilization-management expectations, observation requirements, Condition Code 44 processes, prepayment review, and physician-advisor escalation. CDI and coding teams may not always see that part of the process. However, the documentation that supports UR decisions is often the same documentation that later supports coding, billing, claim payment, appeal defense, and medical review.
When CDI and UR operate separately, documentation gaps can be missed. UR may identify that a stay or service is medically necessary, but the provider documentation may not clearly explain why. CDI may identify the severity of illness, risk, treatment intensity, or diagnostic uncertainty, but may not know the status or the medical-necessity concern being evaluated by UR. Coding may later assign codes based on the final record. Still, if the documentation does not support the medical necessity or the required elements of the claim, the organization may remain vulnerable.
TPE exposes those disconnects.
A case may have the correct inpatient order, a reasonable admission decision, and significant clinical acuity. But if the record does not clearly support why inpatient hospital care was required, why observation was not appropriate, or what the provider expected at the time of admission, the claim may be difficult to defend. Another case may involve a clinically appropriate outpatient service, but the record may be missing required documentation elements, signatures, certification language, or encounter support. A diagnosis may be coded correctly, but the documented relationship between that diagnosis and the service billed may be weak.
These are not isolated billing problems, but record integrity problems.
That is why organizations should proactively use TPE concepts, even before a MAC letter arrives.
Organizations should view TPE readiness as a shared documentation-risk process. Denial and medical-review trends should be reviewed across service lines, providers, payers, diagnoses, procedures, and documentation themes. Patterns matter. A single denial may be a case-specific issue, but repeated denials for the same service, diagnosis, certification element, or medical-necessity rationale may signal a broader documentation vulnerability.
CDI and UR should also have a mechanism to share cases in which the clinical picture supports the care being provided. For circumstances in which the documentation not clearly support the status, medical necessity, treatment intensity, or the reason a lower level of care was not appropriate, these are the cases for which concurrent collaboration can prevent the record from leaving the organization incomplete.
Coding should be part of the feedback loop. Coders often encounter recurring documentation gaps at the end of the record, leaving little time to correct them before billing. Their insight can help identify repeated vulnerabilities that may create medical review risk, even when the final code assignment appears technically correct.
Provider education should also be aligned. If CDI, UR, coding, compliance, and revenue cycle are each educating providers from separate angles, the message can become fragmented. A TPE-ready organization gives providers one connected message: the record must support what was done, why it was medically necessary, why the selected status or setting was appropriate, and which required documentation elements must be present.
High-risk cases should also be identified before billing, whenever possible. Cases involving medical-necessity concerns, status questions, certification or recertification requirements, incomplete documentation, or prior denial patterns should not wait for retrospective review if the record can still be clarified.
Physician advisors are also key to this process. Their involvement is most valuable when they are engaged early enough to support complex medical necessity rationale, status determinations, and provider education – while the record can still be strengthened.
This matters because TPE may be retrospective, whereas prevention is concurrent. The claim is reviewed after submission, but the opportunity to reduce error risk occurs upstream, while the documentation, coding, UR review, and clinical rationale can still be aligned.
For CDI professionals, this means expanding our thinking beyond diagnosis capture, in both the inpatient and outpatient settings. Diagnosis specificity, complication and comorbidity/major complication and comorbidity (CC/MCC) impact, Hierarchical Condition Category (HCC) capture, severity of illness, quality reporting, and risk adjustment.
But documentation integrity also includes whether the record supports the reason for the service, the level of care or setting, the clinical decision-making, the risk being managed, and the medical necessity of the treatment, procedure, therapy, or encounter provided.
For coders, this means recognizing when coding accuracy and medical necessity support intersect. The code may be correct, but the claim may still be vulnerable if the documentation does not support the service, setting, required elements, or clinical rationale. Coding teams are often the last line of defense before the claim leaves the organization. Their observations regarding recurring documentation weaknesses should be escalated as part of a broader risk-prevention process.
For UR teams, the CDI and coding partnership helps ensure that the record not only meets review criteria internally, but also clearly communicates the clinical rationale to someone reviewing the case after the fact. The reviewer will not know what the care team intended, unless the record says it.
That is the heart of TPE readiness.
Organizations should not wait for the MAC to identify patterns; hospitals should be identifying their own patterns first. If a MAC would find missing signatures, incomplete certifications, unsupported medical necessity, insufficient encounter documentation, or weak admission rationale, those are issues the organization should already be finding through internal collaboration.
The most effective approach is a closed-loop process.
UR identifies medical necessity and status risks while the patient is still in-house. CDI helps clarify provider documentation supporting acuity, severity, treatment complexity, and rationale. Coding identifies recurring documentation and coding vulnerabilities before final billing. Outpatient CDI identifies gaps in outpatient documentation related to diagnostic specificity, chronic disease burden, encounter support, procedures, therapies, and medical necessity. Compliance and revenue cycle monitor trends in denials, appeals, and medical reviews. Physician advisors support complex determinations and provider education. Together, the organization creates a defensible record before the claim is submitted.
TPE should also change provider education.
The key takeaway for CDI and coding professionals is that TPE is not someone else’s issue. It is a signal that CMS and the MACs are using data to identify patterns where claims and records may not align with Medicare policy. CDI and coding teams are central to preventing that misalignment.
When CDI, coding, UR, and outpatient CDI partner effectively, organizations are better positioned to identify documentation risk early, educate providers consistently, support compliant coding and billing, reduce denials and appeals, and respond more effectively if selected for review.
TPE may be targeted, but the lesson is broad.
Whether the claim is inpatient or outpatient, the lesson is the same: TPE risk begins when the documentation, coding, billed service, medical necessity, and required record elements do not align.
A defensible claim starts with a defensible medical record. And a defensible medical record is built before the claim is reviewed, before the denial is issued, and before the MAC sends the education letter.
References
Centers for Medicare & Medicaid Services. Targeted Probe and Educate. CMS. Page last modified March 4, 2026.
https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medical-review-and-education/targeted-probe-and-educate-tpe
