TPE Spotlight: Understanding Denial Trends for Key Medications

Most medical coders, auditors, and compliance professionals are aware of the Centers for Medicare and Medicaid Services (CMS) Targeted Probe and Educate (TPE) program. It is designed to help providers and suppliers reduce claim denials and appeals through one-on-one help.  

According to CMS, the goal is to facilitate quick improvement. Medicare Administrative Contractors (MACs) work with providers to identify errors and correct them. TPE is intended to increase accuracy in very specific areas. MACs use data analysis to identify: 

1. Providers and suppliers who have high claim error rates or unusual billing practices.
2. Items and services that have high national error rates and are a financial risk to Medicare

Expensive medications have been on the TPE lists of many different MACs across the country. Below are some of the more commonly audited medications through the TPE program, along with some of the more common reason MACs are denying these services: 

J0585 Botox (Botulinum Toxins) 

• The documentation does not support the medical necessity per LCD policy guidelines. 
• The documentation is missing dosage given per site. 
• The documentation is missing a covered indication for the Botox to be given more than every 12 weeks. 
• The documentation does not include a history of the chronic headaches, nor does it identify or link a specific significant disability caused by the headaches, all of which is needed to support the initiation of the treatment. 
• The documentation does not support a significant decrease in the number and frequency of headaches and an improvement in function upon receiving the injections. 
• The documentation does not include the current number of headache days the patient is experiencing. Documentation should include current information on headaches. 
• Evidence of conservative treatment tried and proven unsuccessful should be documented. 
• Frequent cloned documentation. 

J2778 Lucentis (Eye Injections) 

• The documentation does not support the medical necessity per LCD policy guidelines. 
• The submitted documentation does not include a covered indication to support the medical necessity of the service. 
• The submitted documentation and/or billing history supports that the last injection was administered less than 1 month ago. 

J7318-J7332 Hyaluronan or Derivative (Intra-Articular Injections) 

• The documentation does not support the medical necessity per policy guidelines. 
• The documentation does not support improvement of functional capacity for subsequent injections. 
• Frequent cloned documentation. 
• The documentation does not include subjective patient report of knee pain at the time of injection. 
• Incorrect code billed when ultrasound guidance was used. 
• The documentation was missing one or more of the following: a diagnosis and/or history of symptomatic osteoarthritis of the knee, radiologic evidence to support osteoarthritis diagnosis, and documentation to support failure of at least three months of conservative treatment. 
• Documentation was lacking evidence of failed conservative treatment prior to drug administration. 
• Documentation was lacking evidence to support functional limitation of joint. 
• Documentation supported a repeat series of injections initiated before six months elapsed since the prior series of injections. 
• Documentation did not support failure of three months conservative therapy. 
• Documentation did not support the use of a standardized assessment tool to assess functional limitations. 
• Documentation submitted lacked administration method and/or dosage. 
• Documentation submitted did not support the service billed.  

Administration Codes 

It is important to remember that when an audit shows the drug is not medically necessary, it is often concluded that the administration codes would also be medically unnecessary. Many providers are experiencing this when the payor denies the drug, and they are also denying and recouping the funds associated with the administration of that drug. 

Assessing the trends in TPE audits is an excellent way to prepare for internal audits in your organizations. Additionally, reviewing the lists above can help auditors and coders focus on the most likely errors. 

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