Outpatient Rehab Therapeutic Exercise Postpayment Results for October to December 2020

Published 03/30/2021

Postpayment Service-Specific Probe Results for Outpatient Rehabilitation Services in Alabama, Georgia and Tennessee for October to December 2020

Palmetto GBA performed service-specific postpayment probe reviews on for Outpatient Rehabilitation Services CPT Code 97140 – Manual Therapy. 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 12 providers were placed on edit across Alabama, Georgia and Tennessee. A total of 91 claims were reviewed, with 22 of the claims either completely or partially denied, resulting in an overall claim denial rate of 24.18 percent. The total dollars reviewed was $29,725.07, of which $1,300.24 was denied, resulting in a charge denial rate of 4.37 percent. Overall, there were no auto-denied claims in the region.

Alabama Results
A total of five providers were placed on edit in Alabama. A total of 28 claims were reviewed, with 11 of the claims either completely or partially denied. This resulted in a claim denial rate of 39.29 percent. The total dollars reviewed was $10,854.85, of which $827.34 was denied, resulting in a charge denial rate of 7.62 percent. The top denial reasons are identified below, based on dollars denied.

Percent of Total Denials  Denial Code  Denial Description
27.27% 5H164 No Documentation of Medical Necessity
27.27% 5H165 Not Accepted Standard Medical Practice
18.18% 5H169 Services Not Documented
9.09% 5H920 The recommended Protocol Was Not Ordered and/or Followed
9.09% 5H199 Billing Error

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 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 Code  Denial Description Specific “Granular” Denial Findings Number of Occurrences
5H164 No Documentation of Medical Necessity No Documentation of Medical Necessity 3
5H165 Not Accepted Standard Medical Practice Not Accepted Standard Medical Practice 3
5H169 Services Not Documented Services Not Documented 2
5H920 The Recommended Protocol Was Not Ordered and/or Followed The Recommended Protocol Was Not Ordered and/or Followed 1
5H199 Billing Error Billing Error 1

Georgia Results
A total of two providers were placed on edit in Georgia. A total of 31 claims were reviewed, with seven of the claims either completely or partially denied. This resulted in a claim denial rate of 22.58 percent. The total dollars reviewed was $10,386.12, of which $338.21 was denied, resulting in a charge denial rate of 3.26 percent. The top denial reasons are identified below, based on dollars denied.

Percent of Total Denials  Denial Code  Denial Description
71.43% 5H920 The Recommended Protocol Was Not Ordered and/or Followed
14.29% 5H165 Not Accepted Standard Medical Practice
14.29% 5H199 Billing Error

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 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 Code  Denial Description Specific “Granular” Denial Findings Number of Occurrences
5H920 The Recommended Protocol Was Not Ordered and/or Followed The Recommended Protocol Was Not Ordered and/or Followed 5
5H165 Not Accepted Standard Medical Practice Not Accepted Standard Medical Practice 1
5H199 Billing Error Billing Error 1

Tennessee Results
A total of five providers were placed on edit in Tennessee. A total of 32 claims were reviewed, with four of the claims either completely or partially denied. This resulted in a claim denial rate of 12.50 percent. The total dollars reviewed was $8,484.10 of which $134.69 was denied, resulting in a charge denial rate of 1.59 percent. The top denial reasons are identified below, based on dollars denied.

Percent of Total Denials  Denial Code  Denial Description
50% 5H169 Services Not Documented
25% 5H165 Not Accepted Standard Medical Practice
25% 5H920 The Recommended Protocol Was Not Ordered and/or Followed

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 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 Code  Denial Description Specific “Granular” Denial Findings Number of Occurrences
5H169 Services Not Documented Services Not Documented 2
5H165 Not Accepted Standard Medical Practice  No Physician Certification/Recertification 1
5H920 The Recommended Protocol Was Not Ordered and/or Followed  The Recommended Protocol Was Not Ordered and/or Followed 1

Denial Reasons and Prevention Recommendations

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:

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

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 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. If the physician fails to date his or her signature, staff can add “Received Date” in writing, or with a stamp.
  • Clear copies of the medical records should be submitted

References

  • 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

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

References

  • Code of Federal Regulations, 42 CFR — Sections 410.32 and 424.5
  • This article can be located on the Palmetto GBA website using the Search feature: “Responding to an Outpatient Therapy Additional Documentation Request (ADR)”

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

References

  • Code of Federal Regulations, 42 CFR — Section 411.15
  • Social Security Act (SSA) — Section 1862(a)(1)(A)
  • Palmetto GBA Local Coverage Determination (LCD), which is available on the Palmetto GBA website
  • National Coverage Determination (NCD), which is available 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 website (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

5D199/5H199 — Billing Error
Reason for Denial

The services billed were not covered. According to documentation in the medical record, the hospital has billed items and/or services in error. The hospital may not charge the beneficiary for items and/or services that were billed in error.

How to Avoid This Denial

  • Check all bills for accuracy prior to submitting to Medicare
  • Ensure that the documentation submitted, in response to the ADR, corresponds with the date that the service/diagnostic test was rendered, and the dates of service billed

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:

  • 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

The Next Steps
The service-specific targeted medical review edits for Rehabilitation Services CPT Code 97140 — Manual Therapy 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 https://palmettogba.com/palmetto/Mforms.nsf/files/AP-JJ-A-1000.pdf/$File/AP-JJ-A-1000.pdf?Open&
Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 877–567–7271.