Low Biller Probe and Educate Reviews November 2025
Description: Low Biller Probe and Educate Reviews November 2025 Objective Agenda Objective: Discuss certain Part A services that are being targeted for review for low billing providers Agenda Background information on Low Biller Probe and Educate Part
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slide1. Low Biller Probe and Educate Reviews November 2025<br>
slide2. Objective & Agenda Objective: Discuss certain Part A services that are being targeted for review for low billing providers
Agenda
Background information on Low Biller Probe and Educate
Part A services subject to this process
Compliance with the Probe and Educate process Review the legal disclaimers at the end of the presentation.<br>
slide3. Background on Program<br>
slide4. CMS Implemented Program Purpose:
Target and educate low claims billing providers/suppliers that would otherwise not be included in TPE
Implemented to:
Improve review/education process
Reduce appeals
Lower improper billing
Because:
CMS observed positive results from pilot
Expanded reviews to all MACs<br>
slide5. Review Information<br>
slide6. Who May Be Included Providers/suppliers who bill specific identified services
5 -19 claims within a three-month period for identified service<br>
slide7. DRGs Under Review DRG 056 Degenerative Nervous System Disorders w/MCC DRG 057 Degenerative Nervous System Disorders w/o MCC<br>
slide8. Why We Chose These DRGs CERT identified error rate for DRG 057 or 16%
Identified causes were incorrect billing of DRGs 056 and 057<br>
slide9. Type of Review Prepayment review (before claim processes to payment)
Halted in processing by ADR request
Claim moves into a status location SB6000
Next day moves into a status location SB6001
ADR is generated
Once documentation is received, moved to status location SMRDOC<br>
slide10. Probe and Educate Process If chosen for review, you will receive notification letter and call
We will then review a pre-determined number of claims
If compliant, providers will be released from review
Non-compliant after course of review may lead to additional rounds of review<br>
slide11. Documentation<br>
slide12. Documentation Components Admission records
Emergency room records (if applicable)
Physician orders and progress notes
H&P
Physician consultations
Proof of intent to order inpatient services<br>
slide13. Additional Documentation Operative reports
Radiology reports
Laboratory reports
Nursing notes and treatment records<br>
slide14. More Documentation Components Principal diagnosis of degenerative nervous system disorder
Proof of major complication or comorbidity for DRG 056
Diagnostic reports that support medical necessity
Documentation of indicators that were present on admission
Discharge summary and reports<br>
slide15. Resources Diagnosis Related Group (DRG) Validation
Targeted Probe and Educate (TPE) Review Process
Responding to Medical Review Additional Documentation Request (ADR)
Using the Portal to Submit Prepayment/Post Payment and Prior Authorization Review Documentation<br>
slide16. Questions and Answers<br>
slide17. Survey Let us know what you think!
Take time to complete our survey now.
Survey link in chat
Redirect after closing webinar<br>
slide18. Thanks for attending!<br>
slide19. Disclaimers This material is a tool to assist the provider community. Medicare rules change often. Access CMS’ website for current coverage, regulations and rulings.
The basis for answers given today rely on facts given in the question. Medicare rules determine final coverage.Â
Do not record the event as CMS does not allow this for profit making purposes.<br>
slide2. Objective & Agenda Objective: Discuss certain Part A services that are being targeted for review for low billing providers
Agenda
Background information on Low Biller Probe and Educate
Part A services subject to this process
Compliance with the Probe and Educate process Review the legal disclaimers at the end of the presentation.<br>
slide3. Background on Program<br>
slide4. CMS Implemented Program Purpose:
Target and educate low claims billing providers/suppliers that would otherwise not be included in TPE
Implemented to:
Improve review/education process
Reduce appeals
Lower improper billing
Because:
CMS observed positive results from pilot
Expanded reviews to all MACs<br>
slide5. Review Information<br>
slide6. Who May Be Included Providers/suppliers who bill specific identified services
5 -19 claims within a three-month period for identified service<br>
slide7. DRGs Under Review DRG 056 Degenerative Nervous System Disorders w/MCC DRG 057 Degenerative Nervous System Disorders w/o MCC<br>
slide8. Why We Chose These DRGs CERT identified error rate for DRG 057 or 16%
Identified causes were incorrect billing of DRGs 056 and 057<br>
slide9. Type of Review Prepayment review (before claim processes to payment)
Halted in processing by ADR request
Claim moves into a status location SB6000
Next day moves into a status location SB6001
ADR is generated
Once documentation is received, moved to status location SMRDOC<br>
slide10. Probe and Educate Process If chosen for review, you will receive notification letter and call
We will then review a pre-determined number of claims
If compliant, providers will be released from review
Non-compliant after course of review may lead to additional rounds of review<br>
slide11. Documentation<br>
slide12. Documentation Components Admission records
Emergency room records (if applicable)
Physician orders and progress notes
H&P
Physician consultations
Proof of intent to order inpatient services<br>
slide13. Additional Documentation Operative reports
Radiology reports
Laboratory reports
Nursing notes and treatment records<br>
slide14. More Documentation Components Principal diagnosis of degenerative nervous system disorder
Proof of major complication or comorbidity for DRG 056
Diagnostic reports that support medical necessity
Documentation of indicators that were present on admission
Discharge summary and reports<br>
slide15. Resources Diagnosis Related Group (DRG) Validation
Targeted Probe and Educate (TPE) Review Process
Responding to Medical Review Additional Documentation Request (ADR)
Using the Portal to Submit Prepayment/Post Payment and Prior Authorization Review Documentation<br>
slide16. Questions and Answers<br>
slide17. Survey Let us know what you think!
Take time to complete our survey now.
Survey link in chat
Redirect after closing webinar<br>
slide18. Thanks for attending!<br>
slide19. Disclaimers This material is a tool to assist the provider community. Medicare rules change often. Access CMS’ website for current coverage, regulations and rulings.
The basis for answers given today rely on facts given in the question. Medicare rules determine final coverage.Â
Do not record the event as CMS does not allow this for profit making purposes.<br>