Therapy Review Reason Codes and Statements


Palmetto GBA is currently updating systems to incorporate the standardized CMS reason codes and statements. In the interim, please review the list below of Palmetto GBA denial codes and the corresponding CMS reason codes and statements. For more information related to CMS reason codes, please refer to the CMS website.

Palmetto GBA Denial Message/Statement

Palmetto GBA Full Denial Code

Palmetto GBA Partial Denial Code

Palmetto GBA Denial Description

CMS Reason Code

CMS Statement

THE SUBMITTED DOCUMENTATION WAS FOR THE INCORRECT BENEFICIARY. REFER TO CMS INTERNET-ONLY MANUALS (IOMs), 100-08, MEDICARE PROGRAM INTEGRITY MANUAL, CHAPTER 3.

5D169

5H169

Services Not Documented

GEX08

The documentation submitted cannot be matched to a case/claim

THE SUBMITTED DOCUMENTATION WAS FOR THE INCORRECT DATES OF SERVICE. REFER TO CMS INTERNET-ONLY MANUALS (IOMs), 100-08, MEDICARE PROGRAM INTEGRITY MANUAL, CHAPTER 3.

5D169

5H169

Services Not Documented

GEX08

The documentation submitted cannot be matched to a case/claim

THE MEDICAL RECORD DOES NOT SUPPORT THE PRESENCE OF A DISABLING CONDITION THAT IS CAUSING FUNCTIONAL IMPAIRMENT. REFER TO SOCIAL SECURITY ACT,1862(a)(1)(A); CMS INTERNET-ONLY MANUALS (IOMs), 100-08, MEDICARE PROGRAM INTEGRITY MANUAL, CHAPTER 3; CMS INTERNET-ONLY MANUALS (IOMs), 100-02, MEDICARE BENEFIT POLICY MANUAL, CHAPTER 15, SECTION 220.

5D164

5H164

Doc submitted does not support med nec

TP802

The documentation submitted does not support the medical necessity as listed in coverage requirements. Refer to Social Security Act 1862(a)(1)(A), Internet-Only Manual, Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2, Medicare Program Integrity Manual, Chapter 3, Section 3.4.1.3.

THE MEDICAL RECORD DOES NOT SUPPORT THAT THE BENEFICIARY REQUIRES THE SKILLS AND KNOWLEDGE OF A THERAPIST TO TREAT THE DISABLING CONDITION. REFER TO SOCIAL SECURITY ACT, 1862(a)(1)(A); CMS INTERNET-ONLY MANUALS (IOMs), 100-08, MEDICARE PROGRAM INTEGRITY MANUAL, CHAPTER 3; CMS INTERNET-ONLY MANUALS (IOMs), 100-02, MEDICARE BENEFIT POLICY MANUAL, CHAPTER 15, SECTION 220.

5D164

5H164

Doc submitted does not support med nec

TP802

The documentation submitted does not support the medical necessity as listed in coverage requirements. Refer to Social Security Act 1862(a)(1)(A), Internet-Only Manual, Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2, Medicare Program Integrity Manual, Chapter 3, Section 3.4.1.3.

THE DOCUMENTATION SUBMITTED DOES NOT SUPPORT AN EXPECTATION THAT THE BENEFICIARY WILL BENEFIT FROM THE THERAPY SERVICES. REFER TO SOCIAL SECURITY ACT, 1862(a)(1)(A); CMS INTERNE-ONLY MANUALS (IOMs), 100-08, MEDICARE PROGRAM INTEGRITY MANUAL, CHAPTER 3; CMS INTERNET-ONLY MANUALS (IOMs), 100-02, MEDICARE BENEFIT POLICY MANUAL, CHAPTER 15, SECTION 220.

5D164

5H164

Doc submitted does not support med nec

TP802

The documentation submitted does not support the medical necessity as listed in coverage requirements. Refer to Social Security Act 1862(a)(1)(A), Internet-Only Manual, Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2, Medicare Program Integrity Manual, Chapter 3, Section 3.4.1.3.

FOR REVIEW OF 97110, THERAPEUTIC EXERCISE, THE DOCUMENTATION SUBMITTED DOES NOT SUPPORT SERVICES WERE BEING PROVIDED TO DEVELOP STRENGTH, ENDURANCE, ROM AND/OR FLEXIBILITY. REFER TO SOCIAL SECURITY ACT, 1862(a)(1)(A); CMS INTERNET-ONLY MANUALS (IOMs), 100-08, MEDICARE PROGRAM INTEGRITY MANUAL, CHAPTER 3: CMS INTERNET-ONLY MANUALS (IOMs), 100-02, MEDICARE BENEFIT POLICY MANUAL, CHAPTER 15, SECTION 220.

5D164

5H164

Doc submitted does not support med nec

TP802

The documentation submitted does not support the medical necessity as listed in coverage requirements. Refer to Social Security Act 1862(a)(1)(A), Internet-Only Manual, Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2, Medicare Program Integrity Manual, Chapter 3, Section 3.4.1.3.

FOR REVIEW OF 97140, MANUAL THERAPY, THE MEDICAL RECORD DOES NOT SUPPORT SERVICES BEING PROVIDED WERE RELATED TO 1 OF THE 4 CATEGORIES LISTED IN THE LOCAL COVERAGE DETERMINATION (LCD): OUTPATIENT OCCUPATIONAL THERAPY OR LOCAL COVERAGE DETERMINATION (LCD): OUTPATIENT PHYSICAL THERAPY: JOINT MOBILIZATION; MYOFASCIAL RELEASE/SOFT TISSUE MOBILIZATION; MANIPULATION; MANUAL LYMPHATIC DRAINAGE/COMPLEX DECONGESTIVE THERAPY. REFER TO SOCIAL SECURITY ACT, 1862(a)(1)(A); CMS INTERNET-ONLY MANUALS (IOMs), 100-08, MEDICARE PROGRAM INTEGRITY MANUAL, CHAPTER 3; CMS INTERNET-ONLY MANUALS (IOMs), 100-02, MEDICARE BENEFIT POLICY MANUAL, CHAPTER 15, SECTION 220; LOCAL COVERAGE DETERMINATION (LCD): OUTPATIENT OCCUPATIONAL THERAPY (L34427), LOCAL COVERAGE DETERMINATION (LCD): OUTPATIENT PHYSICAL THERAPY (L34428).

5D164

5H164

Doc submitted does not support med nec

TP802

The documentation submitted does not support the medical necessity as listed in coverage requirements. Refer to Social Security Act 1862(a)(1)(A), Internet-Only Manual, Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2, Medicare Program Integrity Manual, Chapter 3, Section 3.4.1.3.

FOR REVIEW OF 97112, NEUROMUSCULAR RE-EDUCATION, THE DOCUMENTATION DOES NOT SUPPORT THE SERVICES WERE INTENDED FOR IMPAIRMENTS WHICH AFFECT THE BODY'S NEUROMUSCULAR SYSTEM (E.G. POOR STATIC OR DYNAMIC SITTING/STANDING BALANCE, LOSS OF GROSS AND FINE MOTOR COORDINATION, TILT TABLE OR STANDING TABLE, HYPO/HYPERTONICITY) AND IMPROVEMENT OF MOTOR CONTROL AND MOTOR LEARNING. REFER TO SOCIAL SECURITY ACT, 1862(a)(1)(A); CMS INTERNET-ONLY MANUALS (IOMs), 100-08, MEDICARE PROGRAM INTEGRITY MANUAL, CHAPTER 3; CMS INTERNET-ONLY MANUALS (IOMs), 100-02, MEDICARE BENEFIT POLICY MANUAL, CHAPTER 15, SECTION 220.

5D164 

5H164

Doc submitted does not support med nec

TP802

The documentation submitted does not support the medical necessity as listed in coverage requirements. Refer to Social Security Act 1862(a)(1)(A), Internet-Only Manual, Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2, Medicare Program Integrity Manual, Chapter 3, Section 3.4.1.3.

THE EVALUATION FOR THERAPY SERVICES WAS NOT SUBMITTED FOR REVIEW. REFER TO CMS INTERNET-ONLY MANUALS (IOMs), 100-08, MEDICARE PROGRAM INTEGRITY MANUAL, CHAPTER 3; CMS INTERNET-ONLY MANUALS (IOMs), 100-02, MEDICARE BENEFIT POLICY MANUAL, CHAPTER 15, SECTION 220.

5D169

5H169

Services Not Documented

TP100

The documentation submitted did not include an initial evaluation to support the therapy service(s) billed. Refer to Social Security Act (SSA) 1862, Internet Only Manual (IOM), Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.3.B-C

THE EVALUATION FOR THERAPY SERVICES WAS NOT SIGNED. REFER TO CMS INTERNET-ONLY MANUALS (IOMs), 100-08, MEDICARE PROGRAM INTEGRITY MANUAL, CHAPTER 3; CMS INTERNET-ONLY MANUALS (IOMs), 100-02, MEDICARE BENEFIT POLICY MANUAL, CHAPTER 15, SECTION 220.

5FFSG

5CFSG

Missing or Illegible Signature

TP101

The documentation submitted did not include all the required elements of an initial
evaluation including diagnosis or condition description to be treated, current objective
measurable function, clinician’s clinical judgments, prognosis for premorbid return,
signature of qualified clinician. Refer to 42 CFR § 409.44 (c)(1)(iv), Internet Only
Manual (IOM), Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, Section
220.3.C; Internet Only Manual (IOM), Pub 100-08, Medicare Program Integrity
Manual, Chapter 3, Section 3.3.2.4

THE SIGNATURE DOES NOT INCLUDE THE APPROPRIATE PROFESSIONAL IDENTIFICATION TO SUPPORT THAT THE EVALUATION WAS PERFORMED BY A THERAPIST/PHYSICIAN/NON-PHYSICIAN PRACTITIONER. REFER TO CMS INTERNET-ONLY MANUALS (IOMs), 100-08, MEDICARE PROGRAM INTEGRITY MANUAL, CHAPTER 3; CMS INTERNET-ONLY MANUALS (IOMs), 100-02, MEDICARE BENEFIT POLICY MANUAL, CHAPTER 15, SECTION 220.

5D164

5H164

Doc submitted does not support med nec

TP101

The documentation submitted did not include all the required elements of an initial
evaluation including diagnosis or condition description to be treated, current objective
measurable function, clinician’s clinical judgments, prognosis for premorbid return,
signature of qualified clinician. Refer to 42 CFR § 409.44 (c)(1)(iv), Internet Only
Manual (IOM), Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, Section
220.3.C; Internet Only Manual (IOM), Pub 100-08, Medicare Program Integrity
Manual, Chapter 3, Section 3.3.2.5

THE EVALUATION DOES NOT INCLUDE THE IMPAIRMENT BASED DIAGNOSIS, DESCRIPTION OF PROBLEMS TO BE TREATED AND IDENTIFY THE IMPACTED BODY PART. REFER TO SOCIAL SECURITY ACT, 1862(a)(1)(A); CMS INTERNET-ONLY MANUALS (IOMs), 100-08, MEDICARE PROGRAM INTEGRITY MANUAL, CHAPTER 3; CMS INTERNET-ONLY MANUALS (IOMs), 100-02, MEDICARE BENEFIT POLICY MANUAL, CHAPTER 15, SECTION 220.

5D164

5H164

Doc submitted does not support med nec

TP101

The documentation submitted did not include all the required elements of an initial
evaluation including diagnosis or condition description to be treated, current objective
measurable function, clinician’s clinical judgments, prognosis for premorbid return,
signature of qualified clinician. Refer to 42 CFR § 409.44 (c)(1)(iv), Internet Only
Manual (IOM), Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, Section
220.3.C; Internet Only Manual (IOM), Pub 100-08, Medicare Program Integrity
Manual, Chapter 3, Section 3.3.2.6

THE CONDITIONS AND COMPLEXITIES THAT MAY IMPACT THE PATIENT'S TREATMENT WERE NOT INCLUDED IN THE EVALUATION. REFER TO SOCIAL SECURITY ACT, 1862(a)(1)(A); CMS INTERNET-ONLY MANUALS (IOMs), 100-08, MEDICARE PROGRAM INTEGRITY MANUAL, CHAPTER 3; CMS INTERNET-ONLY MANUALS (IOMs), 100-02, MEDICARE BENEFIT POLICY MANUAL, CHAPTER 15, SECTION 220.

5D164

5H164

Doc submitted does not support med nec

TP101

The documentation submitted did not include all the required elements of an initial
evaluation including diagnosis or condition description to be treated, current objective
measurable function, clinician’s clinical judgments, prognosis for premorbid return,
signature of qualified clinician. Refer to 42 CFR § 409.44 (c)(1)(iv), Internet Only
Manual (IOM), Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, Section
220.3.C; Internet Only Manual (IOM), Pub 100-08, Medicare Program Integrity
Manual, Chapter 3, Section 3.3.2.7

THE EVALUATION DOES NOT INCLUDE THE USE OF TOOLS WITH OBJECTIVE MEASUREMENTS TO SUPPORT THAT THERAPY WAS NEEDED. REFER TO SOCIAL SECURITY ACT, 1862(a)(1)(A); CMS INTERNET-ONLY MANUALS (IOMs), 100-08, MEDICARE PROGRAM INTEGRITY MANUAL, CHAPTER 3; CMS INTERNET-ONLY MANUALS (IOMs), 100-02, MEDICARE BENEFIT POLICY MANUAL, CHAPTER 15, SECTION 220.

5D164 TP101

5H164

Doc submitted does not support med nec

TP101

The documentation submitted did not include all the required elements of an initial
evaluation including diagnosis or condition description to be treated, current objective
measurable function, clinician’s clinical judgments, prognosis for premorbid return,
signature of qualified clinician. Refer to 42 CFR § 409.44 (c)(1)(iv), Internet Only
Manual (IOM), Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, Section
220.3.C; Internet Only Manual (IOM), Pub 100-08, Medicare Program Integrity
Manual, Chapter 3, Section 3.3.2.8

THE PLAN OF CARE (POC) WAS NOT SUBMITTED FOR THE DATES OF SERVICE BILLED. REFER TO 42 CODE OF FEDERAL REGULATIONS (CFR), 424.5(a)(6); CMS INTERNET-ONLY MANUALS (IOMs), 100-08, MEDICARE PROGRAM INTEGRITY MANUAL, CHAPTER 3; CMS INTERNET-ONLY MANUALS (IOMs), 100-02, MEDICARE BENEFIT POLICY MANUAL, CHAPTER 15, SECTION 220.

5D169

5H169

 

TP000

The documentation submitted did not support a plan of care for the therapy service(s).
Refer to Social Security Act (SSA) 1862; 42CFR§410.61(a), 42 CFR § 409.17,
Internet Only Manual (IOM), Pub 100-02, Medicare Benefit Policy Manual, Chapter
15, Section 220.1.2

THE PLAN OF CARE (POC) WAS NOT SIGNED. REFER TO CMS INTERNET-ONLY MANUALS (IOMs), 100-08, MEDICARE PROGRAM INTEGRITY MANUAL, CHAPTER 3; CMS INTERNET-ONLY MANUALS (IOMs), 100-02, MEDICARE BENEFIT POLICY MANUAL, CHAPTER 15, SECTION 220.

5FFSG

5CFSG

Missing or Illegible Signature

TP001

Documentation does not support the plan of care was established and signed by a
qualified clinician/practitioner. Refer to Social Security Act (SSA) 1861(p)(2);
42CFR§410.61(b), 42 CFR § 409.17, Internet Only Manual (IOM), Pub 100-02,
Medicare Benefit Policy Manual (MBPM), Chapter 15, Section 220.1.2A, MBPM,
Chapter 15, Sections 220(A)

THE SIGNATURE DOES NOT INCLUDE THE APPROPRIATE PROFESSIONAL IDENTIFICATION TO SUPPORT THE PLAN OF CARE WAS ESTABLISHED BY A THERAPIST/PHYSICIAN/NON-PHYSICIAN PRACTITIONER. REFER TO CMS INTERNET-ONLY MANUALS (IOMs), 100-08, MEDICARE PROGRAM INTEGRITY MANUAL, CHAPTER 3; CMS INTERNET-ONLY MANUALS (IOMs), 100-02, MEDICARE BENEFIT POLICY MANUAL, CHAPTER 15, SECTION 220.

5D162

5H162

No Valid Plan of Care

TP001

Documentation does not support the plan of care was established and signed by a
qualified clinician/practitioner. Refer to Social Security Act (SSA) 1861(p)(2);
42CFR§410.61(b), 42 CFR § 409.17, Internet Only Manual (IOM), Pub 100-02,
Medicare Benefit Policy Manual (MBPM), Chapter 15, Section 220.1.2A, MBPM,
Chapter 15, Sections 220(A)

The plan of care did not contain the diagnoses. Refer to Social Security Act (SSA) 1862; 42CFR§410.61(c); 42 CFR § 409.17; Internet Only Manual (IOM), Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.1.2B

5D162

5H162

No Valid Plan of Care

TP005

The plan of care did not contain the diagnoses or long-term goals. Refer to Social Security Act (SSA) 1862; 42CFR§410.61(c); 42 CFR § 409.17; Internet Only Manual (IOM), Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.1.2B

The plan of care did not contain the  long-term goals. Refer to Social Security Act (SSA) 1862; 42CFR§410.61(c); 42 CFR § 409.17; Internet Only Manual (IOM), Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.1.2B

5D162

5H162

No Valid Plan of Care

TP005

The plan of care did not contain the diagnoses or long-term goals. Refer to Social Security Act (SSA) 1862; 42CFR§410.61(c); 42 CFR § 409.17; Internet Only Manual (IOM), Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.1.2B

THE SUBMITTED DOCUMENTATION DID NOT INCLUDE THE REQUIRED CERTIFICATION. REFER TO CMS INTERNET-ONLY MANUALS (IOMs), 100-02, MEDICARE BENEFIT POLICY MANUAL, CHAPTER 15, SECTION 220.

5D165

5H165

No Certification

TP002

The documentation submitted did not support the approval/certification of the plan of care for the therapy service(s). Refer to Social Security Act (SSA) 1862; 42 CFR
§424.24, Internet Only Manual (IOM), Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.1.3 A

THE SUBMITTED DOCUMENTATION DID NOT INCLUDE THE REQUIRED CERTIFICATION. THERE WAS NO DOCUMENTATION TO SUPPORT THAT THE PHYSICIAN/NON-PHYSICIAN PRACTITIONER HAS REVIEWED OR HAS ACCESS TO REVIEW THE CURRENT PLAN OF CARE. REFER TO CMS INTERNET-ONLY MANUALS (IOMs), 100-02, MEDICARE BENEFIT POLICY MANUAL, CHAPTER 15, SECTION 220.

5D165

5H165

No Certification

TP002

The documentation submitted did not support the approval/certification of the plan
of care for the therapy service(s). Refer to Social Security Act (SSA) 1862; 42 CFR
§424.24, Internet Only Manual (IOM), Pub 100-02, Medicare Benefit Policy
Manual, Chapter 15, Section 220.1.3 A

THE DATES OF SERVICE BEING REVIEWED WAS PAST THE 10TH TREATMENT DAY AND THERE WAS NO SUMMARY OF PROGRESS DOCUMENTED BY THE THERAPIST ON OR BEFORE THE FIRST DATES OF SERVICE REVIEWED TO SUPPORT THE ONGOING SERVICES. REFER TO SOCIAL SECURITY ACT, 1862(a)(1)(A); CMS INTERNET-ONLY MANUALS (IOMs), 100-08, MEDICARE PROGRAM INTEGRITY MANUAL, CHAPTER 3; CMS INTERNET-ONLY MANUALS (IOMs), 100-02, MEDICARE BENEFIT POLICY MANUAL, CHAPTER 15, SECTION 220.

5D164

5H164

Doc submitted does not support med nec

TP302

The documentation submitted did not include a progress report which supported the reason(s) for continued service(s). Refer to Internet 42 CFR § 409.44 (c)(2), Internet Only Manual (IOM), Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.3.D                                     

THE TREATMENT NOTES OR OTHER DOCUMENTATION  WERE NOT SUBMITTED. REFER TO CMS INTERNET-ONLY MANUALS (IOMs), 100-08, MEDICARE PROGRAM INTEGRITY MANUAL, CHAPTER 3; CMS INTERNET-ONLY MANUALS (IOMs), 100-02, MEDICARE BENEFIT POLICY MANUAL, CHAPTER 15, SECTION 220.

5D169

5H169

Services Not Documented

TP501

Documentation did not include a treatment note which contained all the required elements including date of treatment, description of modality/procedure to support accurate billing, total treatment minutes/ total timed code treatment minutes and signature of qualified professional. Refer to Internet Only Manual (IOM), Publication 100-2, Medicare Benefit Policy Manual, Chapter 15, Section 220.3.E, IOM, Pub 100-04, Medicare Claims Processing Manual, Chapter 5, Section 20.2
(B)(C), 20.3, Internet Only Manual (IOM), Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4

THE TREATMENT NOTES WERE NOT SIGNED BY ALL PERSONNEL WHO PROVIDED THE CARE ON THE DATES OF SERVICE. REFER TO CMS INTERNET-ONLY MANUALS (IOMs), 100-08, MEDICARE PROGRAM INTEGRITY MANUAL, CHAPTER 3; CMS INTERNET-ONLY MANUALS (IOMs), 100-02, MEDICARE BENEFIT POLICY MANUAL, CHAPTER 15, SECTION 220.

5FFSG

5CFSG

Missing or Illegible Signature

TP501

Documentation did not include a treatment note which contained all the required elements including date of treatment, description of modality/procedure to support accurate billing, total treatment minutes/ total timed code treatment minutes and signature of qualified professional. Refer to Internet Only Manual (IOM), Publication 100-2, Medicare Benefit Policy Manual, Chapter 15, Section 220.3.E, IOM, Pub 100-04, Medicare Claims Processing Manual, Chapter 5, Section 20.2 (B)(C), 20.3, Internet Only Manual (IOM), Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4

THE TREATMENT NOTES OR OTHER SUPPOORTING DOCUMENTATION  FOR EACH OF THE REQUESTED DATES OF SERVICE WERE NOT SUBMITTED. REFER TO CMS INTERNET-ONLY MANUALS (IOMs), 100-08, MEDICARE PROGRAM INTEGRITY MANUAL, CHAPTER 3; CMS INTERNET-ONLY MANUALS (IOMs), 100-02, MEDICARE BENEFIT POLICY MANUAL, CHAPTER 15, SECTION 220.

5D169

5H169

Services Not Documented

TP501

The documentation submitted is incomplete:Documentation did not include a treatment note which contained all the required
elements including date of treatment, description of modality/procedure to support
accurate billing, total treatment minutes/ total timed code treatment minutes and
signature of qualified professional. Refer to Internet Only Manual (IOM),
Publication 100-2, Medicare Benefit Policy Manual, Chapter 15, Section 220.3.E,
IOM, Pub 100-04, Medicare Claims Processing Manual, Chapter 5, Section 20.2
(B)(C), 20.3, Internet Only Manual (IOM), Pub 100-08, Medicare Program Integrity
Manual, Chapter 3, Section 3.3.2.4

THE TREATMENT NOTES DO NOT INCLUDE THE BILLED THERAPY MODALITY AND INTERVENTIONS PROVIDED. REFER TO CODE OF FEDERAL REGULATIONS (CFR), 424.5(a)(6); CMS INTERNET-ONLY MANUALS (IOMs), 100-08, MEDICARE PROGRAM INTEGRITY MANUAL, CHAPTER 3; CMS INTERNET-ONLY MANUALS (IOMs), 100-02, MEDICARE BENEFIT POLICY MANUAL, CHAPTER 15, SECTION 220.

5D920

5H920

The recommended protocol was not ordered and/or followed.

TP501

Documentation did not include a treatment note which contained all the required elements including date of treatment, description of modality/procedure to support accurate billing, total treatment minutes/ total timed code treatment minutes and signature of qualified professional. Refer to Internet Only Manual (IOM), Publication 100-2, Medicare Benefit Policy Manual, Chapter 15, Section 220.3.E, IOM, Pub 100-04, Medicare Claims Processing Manual, Chapter 5, Section 20.2 (B)(C), 20.3, Internet Only Manual (IOM), Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4

THE TIMED MINUTES WERE NOT DOCUMENTED IN EITHER TOTAL TIMED CODED TREATMENT MINUTES OR A BREAKDOWN OF TIMED TREATMENT MINUTES FOR EACH TIMED SERVICE PROVIDED IN THE RECORDS FOR EACH DATES OF SERVICE. REFER TO 42 CODE OF FEDERAL REGULATIONS (CFR), 424.5(a)(6); CMS INTERNET-ONLY MANUALS (IOMs), 100-08, MEDICARE PROGRAM INTEGRITY MANUAL, CHAPTER 3; CMS INTERNET-ONLY MANUALS (IOMs), 100-02, MEDICARE BENEFIT POLICY MANUAL, CHAPTER 15, SECTION 220.

5D920

5H920

The recommended protocol was not ordered and/or followed.

TP501

Documentation did not include a treatment note which contained all the required elements including date of treatment, description of modality/procedure to support accurate billing, total treatment minutes/ total timed code treatment minutes and signature of qualified professional. Refer to Internet Only Manual (IOM), Publication 100-2, Medicare Benefit Policy Manual, Chapter 15, Section 220.3.E, IOM, Pub 100-04, Medicare Claims Processing Manual, Chapter 5, Section 20.2 (B)(C), 20.3, Internet Only Manual (IOM), Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4

THE UNITS BILLED IN FISS WERE NOT APPROPRIATE BASED ON THE NUMBER OF UNITS ALLOWED BY THE TOTAL TIMED CODED TREATMENT MINUTES. REFER TO 42 CODE OF FEDERAL REGULATIONS (CFR) 414.40; CMS INTERNET-ONLY MANUALS (IOMs), 100-08, MEDICARE PROGRAM INTEGRITY MANUAL, CHAPTER 3; CMS INTERNET-ONLY MANUALS (IOMs), 100-04, MEDICARE CLAIMS PROCESSING MANUAL, CHAPTER 5, SECTION 20; AMA HCPCS PROFESSIONAL CODING GUIDELINES.

5D151

5H151

Units Billed More Than Ordered

TP700

The documentation submitted did not support the unit(s) billed. Refer to Internet Only Manual (IOM), Pub 100-4, Medicare Claims Processing Manual (MCPM), Chapter 5, Section 20.2.C

THE PROVIDER BILLED THE CLAIM OR SERVICES AS BILLED IN ERROR. REFER TO CMS INTERNET-ONLY MANUALS (IOMs), 100-08, MEDICARE PROGRAM INTERGITY MANUAL, CHAPTER 3; CMS INTERNET-ONLY MANUALS (IOMs), 100-04, MEDICARE CLAIMS PROCESSING MANUAL, CHAPTER 23.

5D199

5H199

Billing Error

GAK09

Documentation does not support the claim as billed. Refer to Internet-Only
Manual Pub 100-08 Medicare Program Integrity Manual, Chapter 3, Section
3.6.2.4, Pub 100-04 Medicare Claims Processing Manual, Chapter 23





Last Updated: 10/26/2021