The letter arrives addressed to the practice, not to a physician, and the subject line says Notice of Review. A practice manager at a three-provider pulmonology group read it twice before calling us, because it did not ask for anything yet. It said the Medicare Administrative Contractor had selected the practice for a Targeted Probe and Educate review of established patient office visits at level 99215, that additional documentation requests would follow, and that the practice would receive education based on the findings. Two weeks later, 30 requests for records arrived on the same day, each with its own 45-day deadline.
A Targeted Probe and Educate review, TPE for short, is the Medicare contractor's standard medical review process for providers whose billing looks different from their peers or whose claims deny more often than expected. CMS rolled it out to all Medicare Administrative Contractors (MACs) on October 1, 2017 after a pilot, paused it in March 2020 during the public health emergency, and resumed it in the fall of 2021. It is not a fraud investigation. It is a probe, and it is designed so that most practices fix the problem and leave after one round. Whether that happens depends almost entirely on how the practice handles the first 45 days.
Some terms first. An additional documentation request (ADR) is the contractor's formal request for the records behind a specific claim. Prepayment review means the claims in the probe are held and not paid until the review is complete; postpayment review means they were already paid and can be recouped. The error rate is the share of reviewed claims, counted in dollars or in claims depending on the contractor's letter, that the reviewer found unsupported.
Key takeaways
- A TPE review has up to three rounds; each round is a sample of 20 to 40 claims on one topic, followed by a results letter and a one-on-one education session.
- Every ADR has a 45-day response deadline, and a record you do not send counts as a fully denied claim in the error rate.
- If the round one error rate is acceptable to the contractor, you are released from review on that topic for at least a year.
- Between rounds the contractor gives you at least 45 days to make changes before pulling the next sample.
- Failing three rounds means a referral to CMS, and the options from there include 100 percent prepayment review, extrapolated overpayments and revocation of billing privileges.
How you got selected and what the notice letter tells you
Contractors select TPE targets from data. Under the Medicare Program Integrity Manual, the MAC looks for providers with high claim error rates, billing patterns that differ from peers in the same specialty, or services with high national error rates in the Comprehensive Error Rate Testing program. The most common topics we see in office practice are high-level E/M visits, modifier 25, incident-to services, chronic care management, and specific procedures with a history of documentation problems. Each MAC posts its active TPE topics on its website, and it is worth checking that list once a quarter to see whether you bill something on it.
The Notice of Review letter names the topic, the review type (prepayment or postpayment), the sample size, and a contact at the contractor. It usually invites you to call with questions. Do that. The reviewer will tell you how they want records submitted (electronic submission of medical documentation, a portal, fax or mail), whether they want a cover sheet with the claim identifier, and what they consider a complete record for the topic.
The first round: 20 to 40 ADRs and the 45-day clock
The ADRs arrive next, and every one has its own 45-calendar-day deadline from the date on the letter. This is the point at which practices lose reviews without a single documentation problem. A record not received by day 45 is treated as no documentation, the claim is denied in full, and that denial counts in the error rate exactly like a note that failed on the merits. Two missed ADRs in a sample of 30 is close to a 7 percent error rate before a reviewer has read a word.
We run round one as a project with a spreadsheet: one row per ADR, with the claim number, date of service, provider, deadline, the date the record was pulled, the date it was reviewed internally, the date it was sent, and the tracking or confirmation number. Somebody owns the spreadsheet. Records go out at least a week before the deadline, never on the last day.
Before anything is sent, a coder or a clinician who did not write the note reads every record against the topic. For a 99215 probe, that means scoring the medical decision making or the documented time for every visit and writing the result on the internal tracker. This is not an opportunity to change notes; late addenda that appear after an ADR draw attention and can be treated as unreliable. It is an opportunity to make sure the packet is complete: the full encounter note, signed and dated; any orders, results and outside records the note refers to; a signature attestation if a signature is illegible; and, for time-based visits, the time statement.
| Stage | What happens | Your deadline or window | What to have ready |
|---|---|---|---|
| Notice of Review | Letter names the topic, review type and sample size | None, but call the contractor now | Tracker, owner, submission method confirmed |
| ADRs issued | 20 to 40 requests, one per claim | 45 calendar days each | Complete packets, internally scored, sent with confirmation |
| Review and results letter | Contractor reviews and reports the error rate and each denial reason | Typically within 30 days of the last record, varies by MAC | Compare their findings to your internal scoring |
| Education session | One-on-one call or webinar walking through the denials | Scheduled by the contractor; attend it | Questions on each denial category, the right people on the call |
| Improvement period | Time to change templates, training and workflow | At least 45 days before the next sample | Written corrective action plan, internal re-audit |
| Rounds two and three | Same process on a fresh sample | Same 45-day ADR deadlines | Evidence the changes stuck |
| Release or referral | Acceptable rate: off review for at least 12 months. Three failed rounds: referral to CMS | Contractor decides | Keep the file; the topic can come back |
The results letter and the education session
The results letter lists each reviewed claim, whether it was allowed, denied or partially denied, and the reason. It states the error rate and whether the contractor considers it acceptable. Contractors do not publish a single national threshold, and the letters we have seen describe the standard as a rate that is "minor" or "moderate to significant" rather than a fixed percentage; in our experience a rate in the low single digits ends the review and a rate above roughly 15 to 20 percent guarantees another round. Read every denial reason. Group them. A 99215 review that fails because time statements are missing is a different fix from one that fails because the problems addressed do not reach high complexity.
The education session is a one-on-one call with the contractor's clinical reviewer or education staff. It is easy to treat it as a formality, and that is a mistake. The reviewer will walk through the denial categories and often the specific notes, and will answer questions about what would have supported the claim. Bring the physician whose notes were reviewed, the coder, and the person who owns templates. Take notes; round two will be scored against what you hear.
You can appeal individual denied claims from a TPE round through the normal redetermination process, which has a 120-day filing window from the remittance date. Appeals do not change the round's error rate for purposes of the review, but they do recover money on claims where you believe the reviewer was wrong.
Using the 45 days between rounds
If the round one rate is not acceptable, the contractor must give you at least 45 days after the education session before drawing the next sample. This window is where the review is won or lost, and it needs a written plan even in a small practice. The plan should tie every denial category from the results letter to a specific change: a template edit, a training session with a date and attendees, a new pre-bill check, a change to who signs what. Then it needs proof the change worked, which means an internal audit of a fresh sample, at least 20 notes, scored the same way the contractor scored yours.
The worked version looks like this. The pulmonology group's round one rate was 27 percent on 30 claims: six notes leveled on time with no time statement, two with the assessment copied forward from the prior visit, and no other pattern. The corrective plan had three items. The E/M template gained a mandatory total-time field that will not close without a number when time is selected. The physicians spent an hour on the difference between a chronic illness with exacerbation and one that is stable. The coder added a pre-bill check on every 99215 for the next 90 days. The internal re-audit of 25 notes six weeks later found one failure. Round two, on 35 claims, came back at 3 percent, and the release letter followed.
What happens if you fail all three rounds
After three rounds with unacceptable error rates, the contractor refers the practice to CMS, which decides the next step. The options in the Program Integrity Manual include 100 percent prepayment review of the topic, extrapolation of the error rate across a larger universe of paid claims to calculate an overpayment, referral to a Unified Program Integrity Contractor for investigation, and revocation of Medicare billing privileges. Most practices never get here.
Keep the whole file, including your internal scoring and the corrective plan, for at least the period your compliance program specifies. Release from TPE is topic-specific and lasts at least a year; a different topic can be probed at any time, and a good file from the first review shortens the second. If you want a second set of eyes on a sample before it goes to the contractor, or a re-audit between rounds, that is work our audit team does regularly, and the documentation habits that survive a TPE are the same ones we teach in our coder and provider training.
Questions we hear
Can we ask for more time on an ADR?
Contractors generally do not extend the 45-day deadline, and the manual does not require them to. If a record genuinely cannot be produced in time, call the reviewer before the deadline and document the call, but plan as if no extension exists. Send what you have on time rather than nothing late.
Are the claims in a prepayment TPE held from payment the whole time?
Yes. In a prepayment review, the sampled claims are suspended until the reviewer makes a decision, and allowed claims are then paid. The rest of your claims on that topic continue to process normally unless the contractor tells you otherwise.
Should we involve a lawyer?
Not usually for round one, which is an operational review of documentation. We would suggest counsel if the results letter or any contractor communication mentions referral, extrapolation, or a Unified Program Integrity Contractor, or if you discover during your own review that a pattern of claims was billed incorrectly, because that raises overpayment reporting questions that go beyond the probe.
What to do this week
- Check your MAC's current TPE topic list and mark any service your practice bills in volume.
- Decide now who owns a medical review if a notice arrives, and where records requests are logged, so the 45-day clock never starts unnoticed.
- Pull 20 recent claims on your highest-risk topic and score them the way a contractor would; that is a free round zero.
- Confirm that every provider's notes carry a legible signature and, for time-based E/M, a total-time statement.
- Write a one-page ADR response procedure: pull, internal review, packet assembly, send with confirmation, log.
- Put the current CERT and TPE focus areas on the agenda for your next compliance meeting.
