Targeted Probe and Educate Progress Update: Neuromuscular Re-education - 97112

Targeted Probe and Educate Progress Update: Neuromuscular Re-education — 97112

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 Neuromuscular Re-education — 97112 TPE Results are as follows:

Neuromuscular Re-education 97112

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

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.

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

          
Neuromuscular Re-education 97112

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. 5D199/5H199 — Billing Error

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

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

5D199/5H199 — Billing Error

Reason for Denial
The services billed were not covered. According to documentation in the medical record, the hospital has billed items and/or services in error. The hospital may not charge the beneficiary for items and/or services that were billed in error.

How to Avoid a 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

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

• CMS Targeted Probe and Educate (TPE) web page
• Change Request 10249 (PDF, 241.88 KB)