Home Health TPE Edits in 2026: Diagnosis Codes and Claim Types Under Review by Your MAC

Targeted Probe and Educate (TPE) is one of the most common ways home health agencies (HHAs) experience Medicare medical review. Under TPE, a Medicare Administrative Contractor (MAC) selects an agency based on data, reviews a sample of its claims, provides one-on-one education, and repeats the process if the agency's error rate remains too high. After three rounds without sufficient improvement, the MAC may refer the agency to CMS for further action.

What makes TPE manageable is that MACs publish the topics, or edits, they use to select claims. In 2026, home health TPE edits continue to focus on specific claim types and diagnosis codes. Knowing what your MAC is looking for lets you audit those claims first and fix problems before a TPE ADR arrives.

This article explains how TPE works, how MACs choose edits, the diagnosis codes and claim types home health MACs are targeting in 2026, the most common denial reasons, and how to prepare. It is educational and does not replace legal or professional advice. TPE topics change, so agencies should always check their own MAC's current TPE page.

How TPE Works

According to CMS, TPE is designed to help providers reduce claim denials and appeals through one-on-one education. The process generally works as follows:

• The MAC uses data analysis to identify providers with high claim error rates or unusual billing practices, and services with high national error rates.

• The MAC notifies the provider that it has been selected and requests records for a sample of claims, generally 20 to 40 claims per round.

• The MAC reviews the claims and offers one-on-one education to explain errors and how to correct them.

• If the provider's error rate is acceptable, it is removed from review for that topic.

• If not, the provider moves to another round after a period that allows time for improvement, generally at least 45 days after the education session.

• After up to three rounds, providers that continue to have high error rates may be referred to CMS, which may decide on additional actions, such as extrapolation, referral to a Recovery Audit Contractor or Unified Program Integrity Contractor, or other administrative actions.

TPE reviews may be prepayment or postpayment, depending on the edit. Denied claims retain full appeal rights.

Response Deadlines

Agencies generally have 45 days to respond to a MAC ADR, under 42 CFR 405.930 and CMS's ADR guidance. Under 42 CFR 405.930, if the provider does not respond on time, the claim may be denied.

Acceptable Error Rates

Each MAC sets its own threshold for determining whether a provider passes a round. Agencies should check their MAC's TPE materials for the threshold and whether it is calculated by claim count or by dollars.

Notification Changes

Some MACs have changed how they notify providers about subsequent rounds. Agencies should not assume they will receive a separate advance letter before the next round begins and should monitor ADRs closely after each education session.

How MACs Choose TPE Edits

MACs choose TPE topics based on:

• Data showing services or providers with high error rates.

• Comprehensive Error Rate Testing (CERT) findings.

• PEPPER and other data showing outlier patterns.

• OIG reports.

• Prior medical review experience.

• Specific diagnosis codes associated with high denial rates.

• Claim characteristics such as visit counts, length of stay, case-mix group, and new provider status.

Edits often combine claim characteristics and diagnosis codes. For example, an edit may select claims with a low number of visits and a principal diagnosis from a specific list.

Home Health TPE Edits in 2026: What MACs Are Targeting

TPE topics differ among the four home health and hospice MACs: Palmetto GBA (Jurisdiction M), CGS (Jurisdiction 15), National Government Services (Jurisdiction K), and Wellpoint Federal (Jurisdiction 6). The following examples are drawn from contractor guidance published on MAC websites during 2026. Agencies should confirm the current edits for their own MAC.

Low-Visit Claims With Specific Diagnosis Codes

At least one MAC's current home health TPE edits select claims with two to six visits and certain principal diagnosis codes for medical necessity review. The diagnosis codes listed in that contractor's 2026 guidance include:

• I10, essential hypertension.

• I11.0, hypertensive heart disease with heart failure.

• I25.10, atherosclerotic heart disease of the native coronary artery without angina pectoris.

• J44.0, J44.1, J44.81, J44.89, and J44.9, chronic obstructive pulmonary disease codes.

• J18.9, pneumonia, unspecified organism.

• N39.0, urinary tract infection, site not specified.

• I87.2, venous insufficiency.

• Z46.6, encounter for fitting and adjustment of urinary device.

• G20.A1, G20.A2, G20.B1, G20.B2, and G20.C, Parkinson's disease and parkinsonism codes.

Why these claims? Periods with only a few visits for common chronic conditions raise questions about whether the patient needed skilled care and was homebound. Reviewers will look closely at whether skilled nursing or therapy was reasonable and necessary, and whether the record supports eligibility.

New Providers

The same contractor's guidance includes an edit for new providers with at least 50 claim submissions. New agencies are a priority across CMS, consistent with CMS's 2026 enrollment moratorium and enhanced oversight of new providers.

Low Billers

Another MAC has reported results of a CMS Low Biller Probe and Educate process for home health medical necessity, using prepayment review. Agencies with relatively few claims should not assume they are too small to be selected.

Case-Mix, Reimbursement, and Length of Stay

Contractor guidance from another MAC lists home health TPE topics related to:

• HIPPS codes, focusing on whether the case-mix group is supported.

• Increased reimbursement, focusing on claims with higher payments.

• Length of stay, focusing on patients with long stays.

• Therapy services in longer periods of care.

Denial reasons listed for these topics include documentation not supporting homebound status, skilled nursing not medically necessary, missing or invalid certification, and face-to-face encounter requirements not met.

Other Common Targets

Across MACs, home health TPE topics have historically included:

• Eligibility and medical necessity for home health services.

• Long lengths of stay or high numbers of recertifications.

• Claims with specific principal diagnoses, such as hypertension.

• Periods with visits slightly above LUPA thresholds.

• No response to ADRs.

The Most Common TPE Denial Reasons

One MAC's 2026 TPE results list the top home health TPE denial reasons, by share of denials, as:

• Face-to-face documentation missing, incomplete, or untimely: about 26 percent.

• Initial certification invalid: about 20 percent.

• Skilled nursing not medically necessary: about 15 percent.

• Plan of care or certification not signed: about 9 percent.

• Therapy visits not medically necessary: about 9 percent.

Together, these five reasons account for almost 80 percent of that MAC's TPE denials. Most are documentation problems that can be found and fixed through internal review.

What Reviewers Look For on Each Targeted Claim

Eligibility

• Homebound status under Medicare's two-criteria definition.

• A need for intermittent skilled nursing, physical therapy, speech-language pathology, or continuing occupational therapy.

• A plan of care established and periodically reviewed by a physician or allowed practitioner.

• Care under a physician or allowed practitioner.

Certification

• A valid certification signed and dated before billing.

• Required certification statements.

• Face-to-face encounter documentation, including timing, practitioner type, relation to the primary reason, and the encounter date documented by the certifying practitioner.

• Practitioner records that support eligibility.

Medical Necessity of Skilled Services

• For skilled nursing, observation and assessment, teaching and training, management and evaluation, or direct skilled procedures that require a nurse.

• For therapy, skilled interventions, objective measures, and 30-day reassessments.

Coding and Payment

• Principal diagnosis consistent with the focus of care.

• Case-mix group supported by OASIS and coding.

Diagnosis-Specific Documentation Tips

Hypertension and Hypertensive Heart Disease (I10, I11.0)

• Document why the patient's condition is unstable or at risk of change, such as recent medication changes, uncontrolled readings, or recent hospitalization.

• Record specific assessments, including blood pressure trends, weight, edema, and symptoms.

• Document communication with the practitioner and changes to the plan.

• For I11.0, document heart failure symptoms and management.

• Avoid ongoing visits for stable blood pressure checks without a skilled reason.

COPD (J44 Codes) and Pneumonia (J18.9)

• Document respiratory assessments, oxygen saturation, lung sounds, and dyspnea with exertion.

• Document teaching on inhalers, oxygen, and symptom management, with the patient's response.

• Explain how respiratory limitations support homebound status.

Coronary Artery Disease (I25.10)

• Document why skilled observation or teaching is needed, such as new medications, recent procedures, or symptoms.

• Avoid routine monitoring of a stable condition without a skilled need.

Urinary Tract Infection (N39.0) and Urinary Devices (Z46.6)

• For UTI, document the acute condition, treatment, and monitoring needs.

• For urinary devices, document the skilled procedure, such as catheter changes, and why it requires a nurse.

• Document complications or risk factors that require skilled assessment.

Venous Insufficiency (I87.2)

• Document wound or skin assessments, measurements, and treatments if applicable.

• Document why skilled nursing is needed rather than routine care.

Parkinson's Disease (G20 Codes)

• Document functional limitations, falls risk, and the need for skilled therapy or nursing.

• For therapy, document objective measures, skilled interventions, and progress or maintenance needs.

• Explain how the condition supports homebound status.

Low-Visit Periods Generally

• Make sure each visit shows a skilled service.

• Document why the patient needed only a few visits, such as teaching completed or condition stabilized.

• Confirm homebound status is supported even for short periods.

Claim Types That Carry Extra TPE Risk

Beyond specific diagnosis codes, certain claim characteristics consistently draw medical review attention.

Low-Visit Periods

Periods with two to six visits are close to or just above many LUPA thresholds. Reviewers look at whether each visit was skilled and necessary, and whether a patient with so few visits truly needed home health and was homebound. If one visit is not supported, payment may change.

Early Periods From the Community

Community-admitted early periods rely heavily on the face-to-face encounter and the referring practitioner's records, because there is no recent hospital record to support eligibility. Certification and face-to-face errors are common in these periods.

Late Periods and Recertifications

Late periods require recertification with an estimate of how much longer services will be needed, and reviewers look closely at whether the patient remains homebound and in need of skilled care after a long stay.

High Case-Mix Periods

Periods with high functional impairment levels or high comorbidity adjustments may be reviewed to confirm that OASIS scoring and coding are supported.

Therapy-Heavy Periods

Periods with many therapy visits may be reviewed for skilled need, objective measurement, 30-day reassessments, and reasonable frequency and duration.

Claims From New Agencies

New agencies are a priority for CMS. Edits may select new providers after a set number of claims.

Building an Edit-Matching Report

Most EHR and billing systems can produce a report that flags claims matching your MAC's edits. A useful report includes:

• Claim number, billing period, and period type.

• Principal diagnosis code.

• Number of visits by discipline.

• HIPPS code, clinical group, functional level, and comorbidity adjustment.

• Admission source and timing.

• Length of stay and number of recertifications.

• Payment amount.

• Clinician and referral source.

Run the report monthly, sample flagged claims for review, and track results over time.

The Cost of Failing TPE

Failing TPE rounds has consequences beyond individual denials:

• Additional rounds of review, with more ADRs and staff time.

• Delayed cash flow for prepayment reviews.

• Possible referral to CMS after three rounds, with potential extrapolation or referral to other contractors.

• Increased risk of future data-driven selection.

• In Review Choice Demonstration states, problems found in TPE often reflect the same weaknesses that lower RCD affirmation rates.

Preparing for TPE Before You Are Selected

Step 1: Check Your MAC's Current Edits

Visit your MAC's TPE page and note every home health edit, including diagnosis codes, visit counts, and claim characteristics.

Step 2: Pull Matching Claims

Run a report of your claims from the past six to twelve months that match each edit.

Step 3: Audit a Sample

Review a sample of matching claims against MAC review standards, focusing on face-to-face documentation, certification, homebound status, and skilled need.

Step 4: Calculate Your Error Rate

Calculate your error rate using the same method your MAC uses, whether by claim count or by dollars.

Step 5: Fix Root Causes

Provide targeted education, update templates, strengthen intake and certification processes, and engage referral sources.

Step 6: Address Overpayments

If audits find claims paid in error, evaluate obligations under the 60-day overpayment rule at 42 CFR 401.305.

Step 7: Prepare Your ADR Process

Make sure ADRs reach the right person, are logged on the day they arrive, and are answered with complete records well before the deadline.

When a TPE ADR Arrives

• Read the letter to identify the topic, number of claims, and deadline.

• Assemble complete records for each claim, including referral and practitioner records, the face-to-face encounter, certification, plan of care, orders, OASIS, and visit notes.

• Conduct a pre-submission review using a checklist.

• Submit electronically, such as through esMD or the MAC portal, and keep proof of submission.

• Track each claim's decision.

Making the Most of TPE Education

• Attend the education session and invite clinical and intake leaders.

• Ask specific questions about each denial.

• Document what was learned and the changes made.

• Use the time between rounds to retrain staff and conduct internal audits.

Appealing TPE Denials

TPE denials are initial determinations with full appeal rights. Agencies should appeal claims they believe were denied incorrectly, especially where documentation existed but was not submitted or was misread. Successful appeals recover revenue, though the TPE round result is generally based on the original review.

What Happens After Three Rounds

Providers that do not improve after three rounds may be referred to CMS. CMS may decide on actions such as extended review, referral to a RAC or UPIC, extrapolation, or other administrative actions. This makes early rounds critical.

A TPE Readiness Checklist

• We know our MAC's current home health TPE edits.

• We run a monthly report of claims matching those edits.

• We audit a sample of matching claims each quarter.

• We know our error rate calculated the way our MAC calculates it.

• Face-to-face documentation is checked at intake.

• Certifications and plans of care are signed before billing.

• Homebound and skilled need documentation is reviewed for every period.

• ADRs are logged on arrival and answered well before the deadline.

• Staff know how to request and attend TPE education.

• We track denials and appeal incorrect ones.

Working With Referral Sources on TPE Topics

Because many TPE denials trace back to practitioner documentation, agencies should share TPE trends with referral sources.

• Explain which diagnoses and claim types the MAC is reviewing.

• Share common face-to-face and certification problems.

• Provide a simple checklist practitioners can use when ordering home health.

• Follow up when a referral source's documentation leads to denials.

A Note on Prepayment Versus Postpayment TPE

Some TPE edits use prepayment review, so claims are held until the MAC decides, which affects cash flow. Others start with postpayment review and move to prepayment review in later rounds. Agencies should read each TPE letter carefully to understand the review type and plan for its effect on cash flow.

Key Takeaways

• TPE edits are published by each MAC, so agencies can audit the targeted claims in advance.

• In 2026, edits focus on low-visit claims with chronic disease diagnoses, new and low-billing providers, case-mix and reimbursement, and length of stay.

• Most TPE denials come from face-to-face documentation, certifications, signatures, and skilled need.

• Passing the first round avoids the cost and risk of later rounds.

Frequently Asked Questions

How many claims are reviewed in a TPE round?

Generally 20 to 40 claims per round.

How many rounds are there?

Up to three rounds, with education after each round.

Which home health diagnosis codes are being targeted in 2026?

At least one MAC's 2026 edits target low-visit claims with codes such as I10, I11.0, I25.10, J44 codes, J18.9, N39.0, I87.2, Z46.6, and G20 codes. Other MACs target topics such as HIPPS codes, increased reimbursement, length of stay, and low billers. Check your MAC's current list.

What are the most common TPE denial reasons?

Face-to-face documentation problems, invalid initial certifications, skilled nursing not medically necessary, unsigned plans of care or certifications, and therapy not medically necessary.

Can TPE denials be appealed?

Yes. TPE does not change appeal rights.

Conclusion

Home health TPE in 2026 focuses on predictable areas: low-visit claims with specific chronic disease diagnoses, new and low-billing providers, case-mix and reimbursement outliers, and long lengths of stay. The denial reasons are equally predictable: face-to-face documentation, certifications, signatures, and skilled need. By checking their MAC's current edits, auditing matching claims, fixing documentation problems, and preparing a strong ADR process, home health agencies can pass TPE in the first round or avoid selection altogether.

How HealthBridge Can Help

HealthBridge is a healthcare management consulting firm that helps home health agencies prepare for and respond to TPE through edit-matched claim audits, ADR packet reviews, education planning between rounds, root cause analysis, and appeals support. If your agency wants to get ahead of your MAC's TPE edits, please get in touch with us. We will be happy to help you with this topic.

References

• Centers for Medicare & Medicaid Services. Targeted Probe and Educate (TPE). https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medical-review-and-education/targeted-probe-educate-tpe

• Centers for Medicare & Medicaid Services. Additional Documentation Request. https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medical-review-education/additional-documentation-request

• Centers for Medicare & Medicaid Services. Medicare Program Integrity Manual, Chapter 3, Verifying Potential Errors and Taking Corrective Actions. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/pim83c03.pdf

• Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 7, Home Health Services. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c07.pdf

• Centers for Medicare & Medicaid Services. Comprehensive Error Rate Testing (CERT). https://www.cms.gov/data-research/monitoring-programs/improper-payment-measurement-programs/comprehensive-error-rate-testing-cert

• Centers for Medicare & Medicaid Services. CMS Announces Aggressive Nationwide Crackdown on Fraud with Six-Month Hospice and Home Health Agency Enrollment Moratoria (May 13, 2026). https://www.cms.gov/newsroom/press-releases/cms-announces-aggressive-nationwide-crackdown-fraud-six-month-hospice-home-health-agency-enrollment

• Electronic Code of Federal Regulations. 42 CFR 405.930, Failure to Respond to Additional Documentation Requests. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-405/subpart-I/subject-group-ECFRba80b2c5e3f1227/section-405.930

• Electronic Code of Federal Regulations. 42 CFR 424.22, Requirements for Home Health Services. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-424/subpart-B/section-424.22

• Electronic Code of Federal Regulations. 42 CFR 401.305, Requirements for Reporting and Returning of Overpayments. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-A/part-401/subpart-D/section-401.305

• Centers for Disease Control and Prevention, National Center for Health Statistics. ICD-10-CM. https://www.cdc.gov/nchs/icd/icd-10-cm/index.html