Target Probe and Educate (TPE)

Who is TPE?

TPE (Target Probe and Educate) is a data‑driven MAC review that uses small claim samples and one‑on‑one education to fix billing and documentation errors before stricter actions are taken. It focuses on providers or services with higher error rates or unusual billing patterns, while most compliant providers are never selected.

Reviews typically involve 20–40 claims per round, with education after each round, and persistent high errors after three rounds may lead to CMS escalation such as additional TPE rounds, 100% prepay review, extrapolation, or RAC/UPIC referral.

How they select audit targets 

MACs combine provider/service/beneficiary‑specific data, historical claims trends, CERT error findings, and other federal reports (OIG/GAO/RAC) to flag outliers and high‑risk topics. Providers with compliant claims aren’t selected.

Common triggers include high denial rates vs. peers, sudden utilization shifts, frequent “high‑risk” HCPCS/CPT use, repeated documentation gaps, and outlier patterns identified in national error data.

What’s their current focus?

• Medical necessity not demonstrated: coverage criteria not tied to clinical findings; missing “reasonable & necessary” rationale.
• Signature/authentication gaps, dates, credential issues; missing plan of care or cert/recert (therapy, home health).
• Policy/limit misses: LCD/LCA/NCD rules, frequency caps, (e.g. KX use without supporting documentation).
• E/M & psychotherapy specificity: time/complexity not supported; psychotherapy content lacks elements required for 90832/90834/90837.
• Procedure‑specific documentation (e.g., wound debridement: depth, method, tissue type, measurements, medical necessity for frequency/extent).
• ESRD dialysis frequency rationale; modality documentation aligned with LCD.
• Lab/definitive drug testing: ordering provider intent, medical necessity, and result utilization.

How your documentation can protect you.  

• E/M: Documentation of clear medical decision making or time; link problems, data, and risk; reconcile problem lists vs. “personal history of” conventions to avoid HCC creep. (E/M is an active TPE focus at several MACs.)
• Therapy: Plan of care, certification/recertification, objective measures of progress, KX justification when used; time elements aligned to billed codes.
• Psychotherapy: Modality, time, therapeutic interventions, patient response/plan; differentiate from E/M add‑on.
• Wound care: Depth, method/extent, tissue type removed, wound measurements pre/post, clinical necessity for frequency; align to local coverage.
• ESRD: Frequency and modality rationale tied to beneficiary condition & LCD/Article criteria.
• Lab/drug testing: Ordering medical necessity and how results influenced care.

I’ve been selected, now what?

The TPE process begins with a notice identifying the service under review, followed by an ADR (Additional Documentation Request) for a small sample of claims. The MAC reviews the documentation, issues a results letter outlining any errors, and provides mandatory one‑on‑one education with about 45–56 days for improvement. This cycle may repeat for up to three rounds, after which persistent high error rates can trigger CMS escalation, while low or zero errors allow the provider to exit the TPE process.

Auditing and Monitoring:

• Review Novitas JH: Current TPE Activities, Topics/Schedules, and Documentation Checklists this month.
• Select your top 3 exposed services (e.g., E/M, therapy (KX), wound care) and run 10‑chart internal probes against MAC checklists.
• Fix signatures/authentication, orders, reasonable & necessary narratives, and frequency limits; update templates accordingly.
• Build a standard ADR (Additional Documentation Request) packet and POC (Point of Contact) cover sheet workflow, so responses are consistent and complete.
• Pre‑stage education materials for a 45‑day improvement sprint between rounds.

Final Thoughts

The most effective way to avoid becoming the focus of external governmental reviews is to operate in a state of continuous readiness. This means building strong, consistent documentation habits, aligning every billed service with clear medical necessity, and routinely validating your workflows against CMS, MAC, and payer policies.

By implementing prospective internal audits, monitoring high‑risk service lines, maintaining accurate signatures and orders, and promptly correcting even minor trends, organizations can stay well below the radar of data‑driven targeting algorithms.

Consistent education, standardized templates, disciplined ADR response processes, and ongoing compliance engagement across clinical and coding teams not only protect against government scrutiny but also strengthen operational integrity, reduce denial risk, and reinforce a culture where accuracy is the default rather than the goal.

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