Postpayment Service-Specific Probe Results for Outpatient Rehabilitation Services and Therapeutic Exercises for October through December 2020

Palmetto GBA performed service-specific post payment probe review on for Outpatient – Rehabilitation Services CPT Codes 97110 – Therapeutic Exercises. This edit was set in Alabama, Georgia, and Tennessee. The results for the probe review for claims processed October through December 2020 are presented here.

Cumulative Results
A total of 30 providers were placed on edit in Alabama, Georgia, and Tennessee combined. A total of 210 claims were reviewed, with 43 of the claims either completely or partially denied, resulting in an overall claim denial rate of 20.48 percent. The total dollars reviewed was $65,401.53 of which $6,128.47 was denied, resulting in a charge denial rate of 9.37 percent. Overall, there was a total of 22 auto-denied claims in the region.

Alabama Results
A total of 11 providers were placed on edit in Alabama. A total of 93 claims were reviewed, with 21 of the claims either completely or partially denied. This resulted in a claim denial rate of 22.58 percent. The total dollars reviewed was $31,627.30 of which $3,095.24 was denied, resulting in a charge denial rate of 9.79 percent. The top denial reasons are identified, based on dollars denied.

In order to provide more specific information with regard to the denial reasons identified above, a second level of detail was obtained during Medical Review. Each claim that is reviewed may contain more than one type of “granular” error finding. The individual error findings shown below are listed in decreasing order of occurrence, grouped according to the major denial categories listed above.

Georgia Results
A total of 10 providers were placed on edit in Georgia. A total of 49 claims were reviewed, with seven of the claims either completely or partially denied. This resulted in a claim denial rate of 14.29 percent. The total dollars reviewed was $14,076.22 of which $779.88 was denied, resulting in a charge denial rate of 5.54 percent. The top denial reasons are identified, based on dollars denied.

In order to provide more specific information with regard to the denial reasons identified above, a second level of detail was obtained during Medical Review. Each claim that is reviewed may contain more than one type of “granular” error finding. The individual error findings shown below are listed in decreasing order of occurrence, grouped according to the major denial categories listed above.

Tennessee Results
A total of nine providers were placed on edit in Tennessee. A total of 68 claims were reviewed, with 15 of the claims either completely or partially denied. This resulted in a claim denial rate of 22.06 percent. The total dollars reviewed was $19,698.01of which $2,253.35 was denied, resulting in a charge denial rate of 11.44 percent. The top denial reasons are identified, based on dollars denied.

In order to provide more specific information with regard to the denial reasons identified above, a second level of detail was obtained during Medical Review. Each claim that is reviewed may contain more than one type of “granular” error finding. The individual error findings shown below are listed in decreasing order of occurrence, grouped according to the major denial categories listed above.

Denial Reasons and Prevention Recommendations

5D164/5H164 — No Documentation of Medical Necessity

Reason for Denial
This claim was fully or partially denied because the documentation submitted for review does not support the medical necessity of some of the services billed.

How to Avoid This Denial

• Submit all documentation related to the services billed which support the medical necessity of the services
• A legible signature is required on all documentation necessary to support orders and medical necessity
• Use the most appropriate ICD-10-CM codes to identify the beneficiary’s medical diagnosis

For more information, refer to:

• Code of Federal Regulations, 42 CFR, Section 411.15
• Social Security Act (SSA), Section 1862(a)(1)(A)
• Palmetto GBA Local Coverage Determination (LCD) and National Coverage Determination (NCD) articles on the Palmetto GBA website
• CMS Internet-Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4
• The articles below can be located on the Palmetto GBA Web Site (www.PalmettoGBA.com) using the Search feature
• CMS Medicare Learning Network (MLN) Matters article MM6698 (Signature Guidelines for Medical Review Purposes)
• Medicare Medical Records: Signature Requirements Acceptable and Unacceptable Practices

5D169/5H169 — Services Not Documented

Reason for Denial
This claim was partially or fully denied because the provider billed for services/items not documented in the medical record submitted.

How to Avoid This Denial

• Submit all documentation related to the services billed
• Ensure that results submitted are for the date of service billed, the correct beneficiary and the specific service billed

For more information, refer to:

• Code of Federal Regulations, 42 CFR – Sections 410.32 and 424.5
• The article below can be located at Jurisdiction J Part A (palmettogba.com) using the search feature: “Responding to an Outpatient Therapy Additional Documentation Request (ADR)”

5D165/5H165 — No Physician Certification/Recertification

Reason for Denial
For services to be covered by the Medicare program, the plan of care must be certified by the physician or nonphysician practitioner (NPP). Certification means that the physician or NPP has signed and dated the plan of care or some other document that indicates approval of the plan of care. No valid physician certification or recertification was submitted.

How to Avoid This Denial

• The certification must indicate that the beneficiary (1) needed the type of therapy provided, (2) was under the care of a physician, nurse practitioner, clinical nurse specialist, or physician assistant, and (3) was treated under a valid plan of care
• The initial certification should be signed/dated within 30 days of the first day of treatment (including the evaluation)
• The recertification must occur at least every 90 calendar days
• The signature may be written, electronic or stamped. If the physician fails to date his/her signature, staff can add “Received Date” in writing or with a stamp.
• Clear copies of the medical records should be submitted

For more information, refer to:

• 42 (CFR) Code of Federal Regulations, Sections 410.61 and 424.24
• CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220

• Palmetto GBA Local Coverage Determinations
• CMS Manual System, Pub 100-8, Chapter 3, Section 3.4.1.1, D. Signature Requirements

5D920/5H920 — The Recommended Protocol Was Not Ordered and/or Followed

Reason for Denial
Medicare cannot pay for this service because one or more requirements for coverage were not met.

How to Avoid This Denial
Documentation that may be helpful to avoid future denials for this reason may include, but are not limited to, the following:

• Clear physician’s order with indication of need, dose, frequency and route
• Date and time of associated chemotherapy, as applicable

• Relevant history and physical and/or progress notes
  • Clear indication of the diagnosis
  • Clinical signs and symptoms
  • Prior treatment and response as applicable
  • Stage of treatment as applicable
• Documentation of administration

For further information on the above Medicare coverage issue, references include, but are not limited to, these resources:

• Medicare Benefit Policy Manual, Publication 100-02: Chapter 15, Section 50
• Medicare Claims Processing Manual, Publication 100-04: Chapter 17

5D151/5H151 — Units Billed More Than Ordered

Reason for Denial
The physician’s orders submitted did not cover all of the units billed.

How to Avoid This Denial
In order to avoid unnecessary denials for this reason, the provider should ensure that the physician’s orders cover all the services to be billed prior to billing Medicare. When responding to an Additional Documentation Request (ADR), ensure that all orders for services billed are included with the medical records.

For further information on the above Medicare coverage issue, references include, but are not limited to, these resources:

• 42 (CFR) Codes of Federal Regulations, Sections 410.27 and 424.5.
• CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Chapter 17, Sections 90.2

5D162/5H162 – No Valid Plan of Care

Reason for Denial
For services to be covered by the Medicare program, these services must be furnished under a written plan of care and the plan of care must be established before rendering treatment. The plan can be established by the physician or nonphysician practitioner (NPP), the treating physical therapist, occupational therapist, or speech-language pathologist. The NPP can be a physician assistant, nurse practitioner, or clinical nurse specialist. (Only a physician can establish a plan of care in a Comprehensive Outpatient Rehabilitation Facility.)

How to Avoid This Denial
Documentation and tips that may be helpful to avoid future denials for this reason may include, but are not limited to, the following:

• At a minimum, the plan of care should include (1) the diagnosis, (2) long term goals, and (3) type, amount, duration and frequency of the specific therapy service
• Changes in the plan may be made in writing and must be signed by one of the following: the physician, the physical therapist who furnishes the physical therapy services, the occupational therapist who furnishes the occupational therapy services, the speech-language pathologist who furnishes the speech-language pathology services, a registered professional nurse, a nurse practitioner, a clinical nurse specialist or a physician assistant.

For further information on the above Medicare coverage issues, references include, but are not limited to, these resources:

• 42 (CFR) Code of Federal Regulations, Sections 410.61 and 424.24
• CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220
• CMS Manual System, Pub 100-03, Medicare National Coverage Determinations Manual
• Palmetto GBA Local Coverage Determination (LCD) and National Coverage Determination (NCD) articles on the Palmetto GBA website

The Next Steps
The service-specific targeted medical review edits for Rehabilitation Services CPT Codes 97110 – Therapeutic Exercises in Alabama, Georgia, and Tennessee will be continued based on moderate charge denial rates and medium to high impact severity errors. If significant billing aberrancies are identified, provider-specific review may be initiated.

If you are dissatisfied with a claim determination you have the right to request an appeal. Palmetto GBA encourages you to review the documentation originally submitted, and if you believe you have additional supporting documentation you may include this information with your appeal. For more information related to the appeals process please refer to the Redetermination 1st Level Appeal form.

Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 877–567–7271.