Types Of Review
Targeted Probe and Educate (TPE) is run by the MAC. The contractor requests records for a sample of claims, reviews them against the LCD, and provides education. A practice that continues to have a high error rate can go through up to three rounds before referral for further action.
Post-payment reviews by the MAC, the Supplemental Medical Review Contractor and Recovery Audit Contractors look at claims already paid and can result in overpayment demands. Unified Program Integrity Contractors investigate potential fraud and can suspend payments.
What Reviewers Ask For
- The full wound care record for the dates of service, not just the procedure note
- Evidence of conservative care before advanced treatment
- Wound measurements and photographs where available
- Product invoices and lot numbers for skin substitutes
- Physician orders, signatures and credentials
- Supervision documentation for HBOT
Responding
Record requests have deadlines, usually 45 days for TPE, and a missed deadline is treated as a denial. The response should be complete, organized by date of service, and should include a cover letter that points the reviewer to the elements of the LCD the documentation satisfies.
The Appeals Process
Medicare Part B appeals have five levels: redetermination by the MAC (within 120 days of the initial determination), reconsideration by a Qualified Independent Contractor (within 180 days), a hearing before an Administrative Law Judge when the amount in controversy meets the annual threshold, Medicare Appeals Council review, and federal district court. Most wound care denials that are supported by the record are resolved at the first two levels when the appeal cites the LCD and the specific documentation that meets it.
Frequently Asked Questions
- How long does a practice have to respond to a TPE record request?
- Typically 45 days from the request. The practice should confirm the date on the letter, because a late or missing response counts as an error.
- Does PPBS handle the audit response?
- Yes. PPBS assembles the records, prepares the cover letter mapping the documentation to the coverage policy, and manages the appeal if the review results in a denial.
Billing Support For This Specialty
Physicians Professional Billing Services, Inc. has billed wound care, surgical and procedural specialties since 1998, across every Medicare Part B MAC jurisdiction.
Primary Sources
This page is general information about billing and coverage rules and is not legal, coding or reimbursement advice for a specific claim. Coverage policies change; confirm current requirements with CMS and the applicable Medicare Administrative Contractor.