Targeted Probe and Educate Progress Update: Therapeutic Exercise 97110

The Centers for Medicare & Medicaid Services (CMS) Change Request 10249 (PDF, 241.88 KB) implemented the Targeted Probe & Educate (TPE) process, effective October 1, 2017. The following provides JJ Probe 1 and Probe 2 TPE results statistics from January 2, 2018, to February 28, 2020.

Findings
Medical Review initiated Probe review edits for providers identified through data analysis demonstrating high risk for improper payment. Providers have been offered education throughout and upon completion of the JJ Probe 1 and Probe 2 TPE review. Current JJ Probe 1 and Probe 2 Therapeutic Exercise 97110 TPE Results are as follows:

Therapeutic Exercise 97110

Probes Processed January 2, 2018, to February 28, 2020

Findings by State
Palmetto GBA’s overview of results by state for providers who have had edit effectiveness performed for JJ Probe 1 and Probe 2 TPE review from January 2, 2018, to February 28, 2020.

Risk Category
Risk Category is defined based on end of JJ Probe 2 provider error rates. The categories are defined as:

Therapeutic Exercise 97110

Top 5 Denial Reasons January 2, 2018, to February 28, 2020, JJ Probe 1

1. 5D920/5H920 — The Recommended Protocol Was Not Ordered and/or Followed
2. 5D165/5H165 — No Physician Certification/Recertification
3. 5D164/5H164 — No Documentation of Medical Necessity
4. 5D162/5H162 — No Valid Plan of Care
5. 5D169/5H169 — Services Not Documented

Therapeutic Exercise 97110

Top 5 Denial Reasons January 2, 2018, to February 28, 2020, JJ Probe 2

1. 5D164/5H164 — No Documentation of Medical Necessity
2. 5D169/5H169 — Services Not Documented
3. 5D165/5H165 — No Physician Certification/Recertification
4. 56900 — Auto Deny — Requested Records Not Submitted Timely
5. 5D920/5H920 — The Recommended Protocol Was Not Ordered and/or Followed

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 a Denial
Documentation that may be helpful to avoid future denials for this reason may include, but is 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

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 a 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 and 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. Staff may add a “Received” date in writing or with a stamp if the physician fails to date his or her signature
• Clear copies of the medical record should be submitted

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 a Denial

• Submit all documentation related to the service(s) billed which supports the medical necessity of the service(s)
• 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

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 a 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

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 a 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
• Submit all documentation related to the services billed

56900 — Auto Deny — Requested Records Not Submitted Timely 

Reason for Denial
The services billed were not covered because the claim was not submitted or not submitted timely in response to an Additional Documentation Request (ADR). When an ADR is generated, the provider has 45 days from the date the ADR was generated to respond with medical records. In accordance with CMS instructions, if the documentation needed to make a medical review determination is not received within 45 days from the date of the documentation request, Palmetto GBA will make a medical review determination based on the available medical documentation. If the claim is denied, payment will be denied, or an overpayment will be collected.

How to Avoid a Denial

• Be aware of the ADR date and the need to submit medical records within 45 days of the ADR date
• Submit the medical records as soon as the ADR is received
• Monitor the status of your claims in Direct Data Entry (DDE) and begin gathering the medical records as soon as the claim goes to the location of SB6001
• Return the medical records to the address on the ADR. Be sure to include the appropriate mail code or station number. This ensures that your responses are promptly routed to the Medical Review Department.
• Gather all the information needed for the claim and submit it all at one time
• Attach a copy of the ADR request to each individual claim
• If responding to multiple ADR’s, separate each response and attach a copy of the ADR to each individual set of medical records. Make sure each set of medical records is bound securely with one staple in the upper left corner or a rubber band to ensure that no documentation is detached or lost. Do not use paper clips.
• Do not mail packages C.O.D.; we cannot accept them

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.

Education
Providers are offered an individualized education session where each claim denial will be discussed, and any questions will be answered. Palmetto GBA offers a variety of methods for provider education such as webinar sessions, web-based presentations or teleconferences. Other education methods may also be available.

Next Steps
Providers found to be non-compliant (major risk category/denial rate of 21–100%) at the completion of TPE Probe 1 will advance to Probe 2, and providers found to be non-compliant (major risk category/denial rate of 21–100%) at the completion of TPE Probe 2 will advance to Probe 3 of TPE at least 45 days from completion of the 1:1 post probe education call date. Palmetto GBA offers education at any time for providers. Providers do not have to be identified for TPE to request education.

References

• CMS Targeted Probe and Educate (TPE) web page
• Change Request 10249 (PDF, 241.88 KB)