Therapy Providers Score High on TPE Audits

Initial round of audits proves successful for therapy providers.

Therapy providers in the Novitas JL jurisdiction have received good news on the initial round of targeted probe-and-educate (TPE) audits. 

A total of 93 percent of the 102 therapy reviews received a “minor classification.” Of note, a minor classification can include a 0 percent error rate (seems odd that a provider that passes at 100 percent is categorized in the “minor” category). 

A breakdown of the 102 reviews is as follows:

• 95 Total Reviews with Minor Classification (93 percent)
• 3 Total Reviews with Moderate Classification (3 percent)
• 3 Total Reviews with Major Classification (3 percent)
• 1 Total Review with Insufficient Sample (1 percent)

According to Novitas, the most common reasons for denial (or partial denial) were medical necessity and insufficient documentation. Of course, this is what all the contractors and Medicare reviewers say about therapy documentation! But what does it really mean? 

Medical Necessity

There are a whole host of reasons that a service may be deemed not medically necessary, but Novitas cites primarily the lack of a certified plan of care (POC) that contains all the necessary elements and is properly certified and recertified. The information provided in the Novitas report on the first round of audits was taken verbatim from the Medicare Benefits Policy Manual, Chapter 15, Sections 220-230. 

Insufficient Documentation

Providers that did not submit documentation in response to an ADR (additional documentation requests) in a timely manner were tagged with this error. Novitas stated that they made repeated attempts to contact providers prior to marking this as an error. The education component in the report also stated that insufficient documentation may also relate to the documentation in the therapy record matching the date of service submitted on the claim.

Overall, this is a good report, and it reflects well on the therapy industry. The report did not indicate how many providers are moving to the second round of TPE audits, but it would appear that based upon the percentages noted, not many will receive that second invitation. 

The Novitas JL jurisdiction includes the District of Columbia, Maryland, Delaware, New Jersey, and Pennsylvania. The results of the Novitas JH jurisdiction (Mississippi, Louisiana, Arkansas, Texas, Oklahoma, New Mexico and Colorado) have not been posted.

Stay tuned to Monitor Mondays for TPE updates across the Medicare Administrative Contractors (MACs). 

Program Note:

Listen to Nancy Beckley on Monitor Mondays every Monday, 10-10:30 a.m. Eastern.

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