Targeted Probe and Educate Progress Update: Manual Therapy

Published 10/25/2019

The Centers for Medicare & Medicaid Services (CMS) Change Request 10249 (PDF, 242 KB) implemented the Targeted Probe & Educate (TPE) process, effective October 1, 2017. The following provides Probe 1 JM TPE results statistics from October 1, 2017 – September 27, 2019.

Findings
Medical Review initiated Probe review edits for providers identified through data analysis as demonstrating high risk for improper payment. Providers have been offered education throughout and upon completion of the Probe 1 TPE review. Current Probe 1 JM Part A Manual Therapy 97140 TPE Results are as follows:

Manual Therapy 97140

Probes Processed October 1, 2017 – September 27, 2019

Number of Providers with Edit Effectiveness Performed from October 1, 2017 – September 27, 2919Providers Compliant Completed/Removed After Probe 1 EditsProviders Non-Compliant Progressing to TPE Probe 2Providers Non-Compliant/Removed for Other Reason

77

48

29

1

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 October 1, 2017 – September 27, 2019.

StateNumber of Providers with Edit Effectiveness Performed from Oct. 1, 2017 – September 27, 2019Providers Compliant Completed/Removed After Probe 1Providers Non-Compliant Progressing to TPE Probe 2 ProvidersNon-Compliant/ Removed for Other ReasonOverall Charge Denial Rate Per State
N.C.

29

20

9

1

7.4%

S.C.

16

6

10

0

10.1%

Va.

26

19

7

0

7.3%

W.Va.

6

3

3

0

9.8%

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

Risk CategoryError Rate

Minor

0–20%

Major

21–100%


Manual Therapy 97140 Risk Category October 1, 2017 – September 27, 2019 Pie Chart          

Manual Therapy 97140

Top 5 Denial Reasons October 1, 2017 – September 27, 2019

1. 5D165/5H165 — No Physician Certification/Recertification
2. 5D164/5H164 — No Documentation of Medical Necessity
3. 5D920/5H920 — The Recommended Protocol Was Not Ordered and/or Followed
4. 5D162/5H162 — No Valid Plan of Care
5. 5D169/5H169 — Services Not Documented

Manual Therapy 97140 Top Denial Reasons October 1, 2017 – September 27, 2019

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/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/her signature, staff can add “Received Date” in writing or with a stamp.
• Clear copies of the medical records should be submitted

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 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

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

5D162/5H162 – No Valid Plan of Care

Reason for Denial
For services to be covered by the Medicare program, they must be furnished under a written plan of care, and the plan of care must be established before rendering treatment. The plan can be established by the physician or nonphysician practitioner (NPP), the treating physical therapist, occupational therapist or speech-language pathologist. The NPP can be a physician assistant, nurse practitioner or clinical nurse specialist. (Only a physician can establish a plan of care in a Comprehensive Outpatient Rehabilitation Facility.)

How to Avoid a Denial
Documentation and tips that may be helpful to avoid future denials for this reason may include, but are not limited to, the following:

  • At a minimum, the plan of care should include (1) the diagnosis, (2) long term goals and (3) type, amount, duration and frequency of the specific therapy service
  • Changes in the plan may be made in writing and must be signed by one of the following: the physician, the physical therapist who furnishes the physical therapy services, the occupational therapist who furnishes the occupational therapy services, the speech-language pathologist who furnishes the speech-language pathology services, a registered professional nurse, a nurse practitioner, a clinical nurse specialist or a physician assistant

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 a 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

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 percent) at the completion of TPE Probe 1 will advance to Probe 2, and Providers found to be non-compliant (major risk category/denial rate of 21–100 percent) at the completion of TPE Probe 2 will advance to Probe 3 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.

References

• CMS Targeted Probe and Educate (TPE) web page
• Change Request 10249 (PDF, 242 KB)


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