Targeted Probe and Educate Progress Update: JJ Part A Manual Therapy - 97140

The Centers for Medicare & Medicaid Services (CMS) Change Request 10249 (PDF, 241.88 KB) implemented the Targeted Probe and Educate (TPE) process, effective October 1, 2017. The following provides Probe 1 JJ 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 Probe 1 TPE review. Current Probe 1 JJ Part A Manual Therapy 97140 TPE Results are as follows:

Manual Therapy 97140

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 Probe 1 TPE review from January 2, 2018, to February 28, 2020.

Risk Category
Risk Category is defined based on end of Probe 1 provider error rates. The categories are defined as:

Manual Therapy 97140

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

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

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 support 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
  5D169/5H169 — Services Not Documented

Reason for Denial
This claim was partially or fully denied because the provider billed for service(s) and/or item(s) not documented in the medical record submitted.

How to Avoid a Denial

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

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/her signature
• Clear copies of the medical records should be submitted
  

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 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

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.

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 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.

Reference

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