Medical Review TPE Reviews: October 2024 to September 2025 Planned Reviews
Railroad Medicare’s Medical Review (MR) department is currently conducting both postpayment and pre-payment Targeted Probe and Educate (TPE) reviews.
MR will mail an initial notification letter to the providers chosen for review. This letter will explain the TPE process and request a response with the name and phone number of the person who will act as the point of contact (POC) for the provider.
An Additional Documentation Request (ADR) letter, asking for the records for a specific claim, will be sent on each claim selected for review. MR clinicians will review your claim and the additional documentation which you submit. The reason for record review is to confirm that services were rendered according to the Medicare guidelines for medical reasonableness and necessity.
During the TPE review, your POC may be contacted by the MR reviewer. This contact will be to discuss the review findings and, in some cases, to request additional information that could support the claim.
A Remittance Advice (RA) will be generated after MR makes a determination on the claim. The RA will explain if the claim was allowed at the level billed, allowed but at an up-coded or down-coded level, or if the claim was denied. Railroad Medicare will also determine liability for denied services.
The table below has the CPT ®codes that are under review and a link to articles on the code or service.
October 2024 – September 2025 Planned TPE Reviews
| Type of Service | CPT®/HCPCS Code | Code Description |
|---|---|---|
| Ambulance | A0425 | BLS/ALS mileage, per statue mile (in combination with transport codes) |
| Ambulance | A0427 | ALS1, emergency |
| Ambulance | A0429 |
BLS, emergency |
| Ambulance | A0431 | Rotary wing air transport |
| Ambulance | A0436 | Rotary wing air mileage, per statute mile (in combination with air transport code) |
| Drugs/Biologicals | J0178 | Aflibercept injection |
| Drugs/Biologicals | J0897 | Denosumab Injection |
| Drugs/Biologicals | J2778 | Ranibizumab injection |
| Evaluation and Management | 99213 | Office/outpatient visit, established (usually 20–29 minutes time) |
| Evaluation and Management | 99214 | Office/outpatient visit, established (usually 30–39 minutes time) |
| Evaluation and Management | 99215 | Office/outpatient visit, established (usually 40–54 minutes time) |
| Evaluation and Management | 99222 | Initial hospital care |
| Evaluation and Management | 99223 | Initial hospital care |
| Evaluation and Management | 99232 | Subsequent hospital care |
| Radiology | 71045 | X-ray exam chest 1 view |
| Radiology | 71046 | X-ray exam chest 2 views |
| Radiology | 77080 | DXA, bone density axial |
| Radiology | R0070 | Transport portable X-ray |
| Radiology | R0075 | Transport portable X-ray, multiple patients |
| Radiology | Q0092 | Set-up portable X-ray equipment |
CPT® codes, descriptors and other data only are copyright 2023 American Medical Association®. All rights reserved.
More information on the TPE process can be accessed on the CMS TPE web page.
Resources on the Palmetto GBA/Railroad Website