October MAC Medical Review Updates

on Tuesday, 17 October 2017. All News Items | Medicare Coverage

A New Direction

Everyone needs to change directions sometimes. Maybe the current path has become boring or is not producing the expected results. CMS decided their current Medicare Administrative Contractor (MAC) review process needed a new direction to be more effective.  Based on prior success with a pilot program that resulted in “an increase in the acceptance of provider education as well as a decrease in appealed claims decisions” CMS is transitioning to a new MAC review strategy.

Back in August, we published an article about this new strategy for the Medicare medical review process for MACs.  Key elements of the Targeted Probe and Educate Medical Review Strategy as described on the Medicare TPE webpage include:

  • MACs will select claims for services that pose the greatest financial risk to Medicare and/or those that have a high national error rate.
  • MACs will audit only providers/suppliers who have the highest claim error rates or billing practices that vary significantly from their peers.
  • Providers and services to be audited are identified by the MAC through data analysis.
  • The TPE process starts with a review of 20-40 claims followed by one-on-one provider-specific education to address errors.
  • Providers with moderate and high error rates in the first round of reviews will have a second round of 20-40 reviews, followed by additional provider specific one-on-one education.
  • Providers with high error rates after round two will continue to a third and final round of probe reviews and education.
  • Providers with continued high error rates after three rounds of TPE may be referred to CMS for additional action, which may include 100% prepay review, extrapolation, referral to a Recovery Auditor, or other action.
  • Providers may be removed from the review process after any of the three rounds of probe review if they demonstrate low error rates or sufficient improvement in error rates, as determined by CMS. 

Currently, most MACs have published at least an announcement on their website about the new Targeted Probe and Educate.  In addition, current medical review activity is being wrapped up in preparation for the conversion to the TPE process.  Here is information and links for the various MACs from their Part A websites.

Cahaba – Jurisdiction J

  • Cahaba TPE Notification
  • Effective October 1, 2017
  • Cahaba has previously posted a monthly “Current Prepayment Medical Review Log” – at this time, there is no log for the month of October

Novitas Jurisdictions H and L

  • Novitas JH TPE Notification
  • Novitas JL TPE Notification
  • Both Novitas MACs still have a listing of five current active edits and probes.
  • The Novitas TPE pages, in addition to the announcement, contain a list of six Topics for Review under the TPE process. These include:
    • one ESRD facility issue that started Round One on September 1, 2017,
    • a review of Severe Malnutrition for October 23, 2017 for JL only, and  
    • four pending issues –
      • one inpatient rehabilitation (IRF) issue,
      • one skilled nursing facility (SNF) issue,
      • J0897- Denosumab 1 mg (Prolia/Xgeva) review, and
      • G0277-Hyperbaric oxygen under pressure- (HBO) review.

NGS Jurisdictions K and 6

  • NGS Website – You have to sign into the NGS website selecting a state for J6 or JK, then select Medical Review to see the TPE announcement.
  • Effective October 1, 2017
  • NGS continues to have a listing of Medical Review Focus Areas for both jurisdictions but the only new activity for the month was results for review of DRG 247 (Percutaneous Cardiovascular Procedures with Drug-Eluting Stent without MCC). This review had very low error rates and was discontinued.

CGS Jurisdiction 15

  • CGS TPE Notification
  • Effective October 1, 2017
  • CGS also has a Medical Review Activity Log listing the medical review Targeted Probe & Educate edits currently in place. The issues are
    • Review of HCPCS codes 66984, 66983, and 66982 for Cataract Removal and
    • Review of HCPCS codes 62311 for Spinal Injections.

The status of both issues is “pending.”

Noridian Jurisdictions E and F

  • Noridian was part of the initial approved TPE Pilot expansion in July 2017
  • Noridian JE TPE Notification
  • Noridian JF TPE Notification
  • Noridian JE has only one current review (SNF), and published findings from one IRF review and two Denosumab reviews which are now completed.
  • Noridian JF has only one current review (SNF Demand Bill) and “does not have any recent completed pre-payment service specific reviews as CMS has authorized Jurisdiction F to conduct the Targeted Probe and Educate (TPE) Pilot review process.”

WPS Jurisdictions 5 and 8

First Coast JN

  • First Coast has no information on the TPE process on their website at this time.
  • However, they have discontinued all other Medical Review and Probe Audits. All final probe reviews were completed as of April 11, 2017 and all remaining active medical review edits were turned off on September 17, 2017.

Palmetto JM

  • Palmetto has no information on the TPE process on their website at this time.
  • They posted results of two pre-pay service-specific targeted reviews at the end of September and indicated both reviews will continue.
  • Palmetto is in the process of assuming duties for Jurisdiction J which will be complete in January and February 2018. It is possible CMS is allowing them to delay beginning the TPE process until the transition is complete.

Whenever they begin, I hope all MACs continue to post the review issues and education for compliance such as Novitas and CGS are doing already.  I understand the TPE program involves provider specific reviews and individual provider one-on-one education.  But as a provider advocate, this information is extremely helpful in making all providers aware of ‘at risk’ issues which allows them to take proactive steps to ensure Medicare medical necessity criteria are met and supported by the medical record documentation, and that coding and billing are accurate.  I encourage providers to share this request with their MACs and CMS.  I am doing my part to get this request to them, but it may have more impact coming from actual providers.

Good luck to everyone as the Targeted Probe and Educate reviews get underway. Remember to watch carefully for Additional Documentation Requests (ADRs) and respond! Denials for failure to submit records are inexcusable.

The limited MAC medical review activity from last month is listed below.


MACService DescriptionService CodeDateError/Denial RateStatus
NGS JK Percutaneous Cardiovascular Procedures with Drug-Eluting Stent without MCC DRG 247 9/18/2017 3.12% discontinued
Palmetto JM Infliximab, 10 mg HCPCS J1745 9/27/2017 VA - 36.9%
WV - 48.5%
Palmetto JM Major Joint Replacement or Reattachment of Lower Extremity without Major Complication or Comorbidity (MCC) DRG 470 9/27/2017 NC - 28.2%
SC - 40.1%
VA - 30.7%


Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc.  Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system.  In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers.  You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information.  MMP, Inc. is not offering legal advice.  Every reasonable effort has been taken to ensure the information is accurate and useful.




green-iconWe are an environmentally conscious company, dedicated to living “green” both at work and as individuals.


1900 Twentieth Avenue South
Suite 220
Birmingham, AL 35209


This email address is being protected from spambots. You need JavaScript enabled to view it.