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Hospital Takes TPE Complaints to the Top; CMS Makes Changes, Including New PECOS Line

Ultimately it was the gratuitous downcoding of MS-DRGs and the claim denials of hyperbaric oxygen (HBO) therapy under Targeted Probe and Educate (TPE) that led Mercy, a health system in Chesterfield, Missouri, to CMS’s doorstep. Mercy had to appeal MS-DRGs that were downcoded when the Medicare administrative contractor (MAC) rejected a secondary diagnosis of severe protein-calorie malnutrition as well as HBO therapy claims even though they conformed to the diagnosis on Medicare’s national coverage determination. Although Mercy won most of the appeals, its experience represented a lot of what was wrong with TPE, CMS’s national medical review strategy, says Mary Bourland, M.D., vice president of medical documentation at Mercy, who took her concerns about TPE to CMS in Baltimore.

For one thing, the person at the MAC who audits the claim isn’t the same person on the education call, so he or she isn’t steeped in the details, which makes TPE education less meaningful, Bourland says. It’s also sometimes upside-down. “Often the physicians [at hospitals or practices] are more qualified than the nurse auditors on the education call and teaching them, and not the other way around,” Bourland contends. Even if auditors are persuaded they’re wrong, their hands are tied because appeals are the only recourse. There are also more prosaic, but equally important, glitches around the transfer of information to the MAC and mail never reaching the right hands.

The good news is that TPE is slowly improving, according to Bourland and attorney Chris Kenny, with King & Spalding in Washington, D.C. “The agency is willing to make meaningful changes where it feels it can,” he says. For example, providers can now enter a contact person for TPE correspondence in a line that CMS added to the Provider Enrollment, Chain and Ownership System (PECOS), Bourland says. The quality of the education calls has improved, and CMS plans to revise the error rate when providers win appeals, they say. “Going forward, we can expect a different process,” she says.

But hospitals still report problems with TPE, and Mercy’s experience with malnutrition was particularly frustrating, Bourland says. The MAC nurse reviewer had downcoded MS-DRGs with a major complication and comorbidity (MCC) of unspecified severe protein calorie malnutrition (E43) because the documentation didn’t include nutritional edema.

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