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 |
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 |
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 |
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 |
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 |
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). |
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 |
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 |
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 |
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 |
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 |
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 |
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 |