Postpayment Service-Specific Probe Results for Manual Therapy for January through March 2021

Palmetto GBA performed service-specific postpayment probe review on CPT Code 97140 — Manual Therapy. This edit was set in North Carolina, South Carolina, Virginia and West Virginia. The results for the probe review, for claims processed January through March 2021, are presented here.

Cumulative Results 
A total of 856 claims were reviewed in North Carolina, South Carolina, Virginia and West Virginia combined, with 140 of the claims were either completely or partially denied. This resulted in an overall claim denial rate of 16.36 percent. The total dollars reviewed was $217,198.74, of which $17,478.84 was denied, resulting in a charge denial rate of 8.05 percent. Overall, there was a total of 138 auto-denied claims in the region. 

North Carolina Results
A total of 401 claims were reviewed, with 62 of the claims either completely or partially denied. This resulted in a claim denial rate of 15.46 percent. The total dollars reviewed was $94,812.14, of which $6,740.96 was denied, resulting in a charge denial rate of 7.11 percent. The top denial reasons identified, and number of occurrences based on dollars denied are:  

South Carolina Results
A total of 160 claims were reviewed, with 26 of the claims either completely or partially denied. This resulted in a claim denial rate of 16.25 percent. The total dollars reviewed was $49,004.20, of which $3,986.83 was denied, resulting in a charge denial rate of 8.14 percent. The top denial reasons identified, and number of occurrences based on dollars denied are:

Virginia Results
A total of 220 claims were reviewed, with 42 of the claims either completely or partially denied. This resulted in a claim denial rate of 19.09 percent. The total dollars reviewed was $50,196.27, of which $4,989.94 was denied, resulting in a charge denial rate of 9.94 percent. The top denial reasons identified, and number of occurrences based on dollars denied are:

West Virginia Results
A total of 75 claims were reviewed, with 10 of the claims either completely or partially denied. This results in a claim denial rate of 13.33 percent. The total dollars reviewed was $23,012.10, of which $1,761.11 was denied, resulting in a charge denial rate of 7.65 percent. The top denial reasons identified, and number of occurrences based on dollars denied are:

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. Documentation should support:
  • A covered indication or condition for the service billed
  • A physician or NPP is managing the care of the covered indication or condition
  • Any medical history that supports a need for the service 
  • Any diagnostic results or symptomology that supports a need for the service
  • 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

More Information

• 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) — LCD and NCD articles on our website
• CMS Manual System, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4 (PDF, 652.5 KB)
• CMS Medicare Learning Network (MLN) Matters article MM6698 — Signature Guidelines for Medical Review Purposes
• Medicare Medical Records: Signature Requirements Acceptable and Unacceptable Practices
   

5D165/5H165 — No Physician Certification/Recertification

Reason for Denial
For outpatient therapy 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 plan of care must be complete and valid for the certification to be valid
• The physician or NPP signature on the certification must be legible 
• 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 physician or NPP signature on the certification must be legible for the certification to be valid
• If certification is provided on a separate document other than the actual plan of care, there must be documentation to support the certifying physician or NPP had access to the plan of care for review. This can be a statement on the document for the physician or NPP, a fax log showing where the plan of care was forwarded to the physician or NPP, or a note in the therapy record indicating the plan of care was forwarded to the physician or NPP.

More Information

• 42 (CFR) Code of Federal Regulations, Sections 410.61 and 424.24
•  Manual System, Pub 100-02: Medicare Benefit Policy Manual, Publication 100-02: Chapter 15, Section 220
• Palmetto GBA Local Coverage Determinations
  • Outpatient physical therapy
  • Outpatient occupational therapy
  • Outpatient speech language pathology  
• CMS Manual System, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.4.1.1, D — Signature Requirements (PDF, 652.5 KB)
   

5D199/5H199 — Billing Error

Reason for Denial
The services billed were not covered because the documentation provided did not support the claim as billed by the provider.

How to Avoid This Denial
To avoid future denials for this reason:

• 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

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

• CMS Manual System, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.4 (PDF, 652.5 KB)
• CMS Manual System, Pub 100-04, Medicare Claims Processing Manual
   

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
• Ensure that the documentation is complete with proper authentication and the signature is legible

More Information

• Code of Federal Regulations, 42 CFR – Sections 410.32 and 424.5
   

5D151/5H151 — Units Billed More Than Ordered

Reason for Denial 
The medical record provided for the outpatient service did not support the number of units billed on the claim. Per the documentation more units were billed than provided.

How to Avoid This Denial
Under the Outpatient Prospective Payment System (OPPS), when HCPC code reporting is required the number of times the service or procedure was performed, or the amount of the service used must also be accurately reported in the service units.  

• For time-based general outpatient services, make sure the start and end time, or total length of the service is documented clearly in the record
• For other general outpatient services, make sure the amount of the service is documented clearly in the record
• When reporting drugs or biologicals make sure the amount of the drug given is clearly documented and properly converted into units when submitted for payment
• For outpatient therapy services, make sure the timed treatment minutes for the timed services provided are documented clearly in the record

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
• General Outpatient Billing: CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Chapter 4, Section 20.4 (PDF, 1.27 MB)
• Medicare Claims Processing Manual, Publication 100-04: Chapter 17, (PDF, 493.1 KB), Sections 90.2
• Outpatient Rehabilitation: CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Chapter 5, Sections 20.2 (PDF, 693.68 KB)
   

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 medical history documented prior to the DOS and signed by the physician or appropriate nonphysician provider to include:
  • Clear indication of the diagnosis
  • Clinical signs and symptoms
  • Prior treatment and response as applicable
  • Stage of treatment as applicable 
• Ensure the service was provided per the coverage guidelines for the service
• Documentation of  administration

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

• LCD and NCD articles on our website
• Medicare Benefit Policy Manual, Publication 100-02: Chapter 15, Section 50 (PDF, 1.55 MB)
• Medicare Claims Processing Manual, Publication 100-04: Chapter 17, (PDF, 493.1 KB)
• Medicare Benefit Policy Manual, Publication 100-02: Chapter 15, Sections 220 and 230
   

5FFSG/5CFSG — Missing or Illegible Signature 

Reason for Denial
The services billed were not covered because there were missing or illegible provider signature(s), and a signature log or provider attestation was not received.

How to Avoid a Denial

• A legible signature is required on all documentation necessary to support orders and medical necessity
• A signature log or provider attestation must be submitted for review timely (within 20 calendar days) when requested. The 20-day timeframe begins once the contractor makes an actual phone contact with the provider or the date the request letter is received by the post office.
• Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a handwritten or an electronic signature. Stamp signatures are not acceptable.

More Information

• CMS Manual System, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.4.1.1 (PDF, 652.5 KB)
• CMS Medicare Learning Network (MLN) Matters article MM6698 — Signature Guidelines for Medical Review Purposes
   

The Next Steps
The service-specific postpayment medical review edits for CPT Code 97140 Manual Therapy in North Carolina, South Carolina, Virginia and West Virginia 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 (PDF, 237 KB). Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 855–696–0705.