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Infusions: Will your documentation pass a Targeted Probe and Educate Review?

For years, Blue & Co. has received questions from hospitals regarding coding and billing for infusions, as well as documentation requirements. Infusion coding can be some of the most difficult coding for hospitals. It takes a certain understanding of 1) the required hierarchy, 2) what happens if a stop time is not recorded, 3) how to carve out hydration time, 4) what must be documented, and so much more.

We are now seeing a trend from CMS MACs (Medicare Administrative Contractors) focusing on those very questions. CMS relies on a network of MACs to serve as the primary operational contact between the Medicare fee-for-service program and the health care providers enrolled in the program. MACs are multi-state, regional contractors responsible for administering both Medicare Part A and Part B claims.

The purpose of a Targeted Probe and Educate (TPE) review is to help providers reduce claim denials and appeals.

TPE Reviews on Infusions

It has come to our attention that a CMS MAC is performing TPE reviews on infusions. Blue & Co. has not seen a review of this nature in the past. For one facility, 40 claims were reviewed from the emergency department and cancer center.

The results of the TPE were:

  • 5% denied
  • 80% partial payment
  • 15% accepted

The denied and partially paid claims will result in a payment back to Medicare. Currently the OPPS payment rate (Addendum B) for an initial infusion (CPT code 96365) is $208.93.

TPE Infusion Results

The main issues identified during the TPE were:

  • Monitoring
    • For therapeutic infusions periodic monitoring was not documented
    • For highly complex/chemo infusions frequent monitoring was not documented
  • Other
    • Missing start/stop times
    • Order stated IM; administered IV
    • Missing name and credentials for staff administering
    • Missing order(s) for hydration
    • Hydration not supported (concurrent time)
    • Documentation does not support hydration

In the TPE reports, the MAC referenced certain CFR publications and CMS Pub 100 manuals to support their findings.

To better understand the findings and assist our clients, we have reviewed the TPE reports, the CFRs and Pub 100’s in hopes of gaining an understanding of what the MAC is requiring in Hospital documentation and beyond.

Contact Us

If your healthcare organization has any questions over the Targeted Probe and Educate Reviews on infusions, please reach out to your local Blue & Co. Advisor or a member of our Revenue Cycle Team.

Heather Reagan, CPC, CCS-P, CPMA, Revenue Cycle Manager
317.275.7420 | hreagan@blueandco.com

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