Targeted Probe and Educate Progress Update: Manual Therapy - 97140


The Centers for Medicare & Medicaid Services (CMS) Change Request 10249 (PDF, 241.88 KB) implemented the Targeted Probe & Educate (TPE) process, effective October 1, 2017. The following provides JM TPE Probe results statistics from October 1, 2017, to January 31, 2020.

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

Manual Therapy — 97140

Probes Processed October 1, 2017, to January 31, 2020

Number of Providers with Edit Effectiveness Performed from Oct. 1, 2017 – January 31, 2020, Probe 1Providers Compliant Completed/Removed After Probe 1 Edits Providers Non-Compliant Progressing to TPE Probe 2Providers Non-Compliant/Removed for Other Reason

79

49

29

1

Number of Providers with Edit Effectiveness Performed from Oct. 1, 2017 – January 31, 2020, Probe 2Providers Compliant Completed/Removed After Probe 2 EditsProviders Non-Compliant Progressing to TPE Probe 3Providers Non-Compliant/Removed for Other Reason

3

3

0

0

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, to January 31, 2020.

StateNumber of Providers with Edit Effectiveness Performed from Oct. 1, 2017 – January 31, 2020 Probe 1 Providers Compliant Completed/Removed After Probe 1Providers Non-Compliant Progressing to TPE Probe 2Providers Non-Compliant/Removed for Other Reason Overall Charge Denial Rate Per State
North Carolina

30

21

8

1

7.20%

South Carolina

16

6

10

0

10.14%

Virginia

16

19

7

0

7.28%

West Virginia

7

3

4

0

10.31%

StateNumber of Providers with Edit Effectiveness Performed from Oct. 1, 2017 – January 31, 2020 Probe 2 Providers Compliant Completed/Removed After Probe 2Providers Non-Compliant Progressing to TPE Probe 3Providers Non-Compliant/Removed for Other Reason Overall Charge Denial Rate Per State
North Carolina

3

3

0

0

3.06%

South Carolina

0

0

0

0

0%

Virginia

0

0

0

0

0%

West Virginia

0

0

0

0

0%

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 Probe 1

Top 5 Denial Reasons October 1, 2017, to January 31, 2020

  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

Risk Category
Risk Category is defined based on end of Probe 2 provider error rates. The categories are defined as:

Risk CategoryError Rate

Minor

0–20%

Major

21–100%

Manual Therapy 97140 Probe 2

Top 5 Denial Reasons October 1, 2017, to January 31, 2020

  1. 5D164/5H164 — No Documentation of Medical Necessity
  2. 5D165/5H165 — No Physician Certification/Recertification
  3. 5D169/5H169 — Services Not Documented
  4. 5D920/5H920 — The Recommended Protocol Was Not Ordered and/or Followed
  5. 5FFSG/5CFSG — Missing or Illegible Signature

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, these services 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

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.

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%) 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%) 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

 





Last Updated: 03/23/2020