CMS Targeted Probe and Educate (TPE) reviews are now in full swing

What is a Targeted Probe and Educate program?

A Targeted Probe and Educate (TPE) program is a claim review process utilized by the Medicare Administrative Contractor (MACs) designed to help dermatologists reduce claim and billing denials as well as appeals through “one-on-one” corrective action assistance and is overseen by CMS’s Center for Program Integrity (CPI).

The main goal of a TPE is to help dermatologists quickly improve their billing error rate by working, in person, with MACs to identify coding and billing errors and render corrective actions. This targeted dermatologist education is what makes this type of audit different.

TPEs are based on data analysis and other findings indicative of a potential vulnerability including findings from the Comprehensive Error Rate Testing (CERT) Contractor, the Office of Inspector General (OIG), the Government Accountability Office (GAO), or the Recovery Audit Contractors (RACs). When performing TPE reviews, MACs focus on specific dermatologists who report a particular item or service rather than all dermatologists billing the same item or service. MACs will focus only on dermatologists who have the highest claim denial rates or who have billing practices that vary significantly from their peers.

Targeted Probe and Educate in dermatology

When selected for a TPE review, the dermatologist may have a total of up to three rounds of review. A TPE review round involves the review of 20-40 claims per dermatologist, per item, or service. The MACs are limited to a 40-chart request and a service-specific review based on data analysis procedures. After each round, dermatologists are offered individualized education based on the outcome of their review. Depending on the outcome of the first and second reviews, the local MAC personnel will provide instructions on the next steps for the dermatologist.

After each round of review, the MAC will provide “one-on-one” education directly to the dermatologist to help them quickly improve accuracy and reduce claim denials and appeals. Many common errors are simple — such as a missing physician’s signature — and are easily corrected during a round to fix such simple problems more efficiently.

Common claim errors include:


The signature of the certifying physician was not included

Encounter notes did not support all elements of eligibility

Documentation does not meet medical necessity

Missing or incomplete initial certification or recertification

If after the first three rounds of reviews and “one-on-one” education, there are continued high denials, the MAC will refer the dermatologist and the results of the TPE to CMS for additional action, which can include additional rounds of review, 100% pre-payment review, extrapolation, referral to the Recovery Auditor (RA), referral to the Unified Program Integrity Contractor (UPIC), referral for revocation of participation in the Medicare program, etc.

Like all audits, a TPE must be taken seriously and responded to efficiently. The American Academy of Dermatology coding team always reminds dermatologists that every audit from a payer must be considered serious and handled with the utmost efficiency to ensure the medical records submitted support the level of service and/or procedure reported on the claim form.

A TPE review can be discontinued at any time if the appropriate improvement is achieved during the review process.

Targeted Probe and Educate Cycle


Source: CMS Targeted Probe & Educate

What is the purpose of the medical review program?

Medical reviews identify errors through claims analysis and/or medical record review activities. MACs use this information to help ensure they provide proper Medicare payments only for services that meet all Medicare coverage, coding, billing, and medical necessity requirements (and recover any improper payments if the claim was already paid). They also provide education to help ensure future compliance.

A MAC may use any relevant information it deems necessary to make a prepayment or post-payment claim review determination. This includes any documentation submitted with the claim or through an additional documentation request.

Most dermatology practices may never be flagged for a TPE as long as their claimsare compliant with Medicare coding and billing policies. However, if a dermatology practice has high claim error rates or unusual billing practices, and reports items and services that have high national error rates and are a financial risk to Medicare, the practice can be identified through the MACs data analysis to need a TPE.

If your dermatology practice receives a letter from your MAC informing the dermatologist that they have been identified for CMS’s TPE program, know that the request will include the review of claims submitted with a specific CPT as well as documentation, coding and billing compliance with the local or national coverage determination policy requirements as well as the Medicare billing and coding guidance articles.

All current topics for review are listed on the appropriate Part B MAC. Affected dermatologists will be notified in writing with information on the topic(s) being reviewed, the reason(s) for selection which will be supported by data analysis, and the process of review.

For example, the following are active dermatology-related TPEs, by MAC:


Learn more at the CMS page on Targeted Probe and Education.