Postpayment Service-Specific Probe Results for Therapeutic Exercise for July through September 2021


Postpayment Service-Specific Probe Results for Therapeutic Exercise in North Carolina, South Carolina, Virginia and West Virginia for July through September 2021

Palmetto GBA performed service-specific postpayment probe review on CPT Code 97110 — Therapeutic Exercise. This edit was set in North Carolina, South Carolina, Virginia and West Virginia. The results for the probe review, for claims processed July through September, 2021, are presented here.

Cumulative Results
A total of 54 claims were reviewed in North Carolina, South Carolina, Virginia and West Virginia combined, with 32 of the claims were either completely or partially denied. This resulted in an overall claim denial rate of 59.26 percent. The total dollars reviewed were $17,050.09, of which $5,531.51 were denied, resulting in a charge denial rate of 32.44 percent. Overall, there was a total of one auto-denied claim in the region. The top denial reasons were identified, and the number of occurrences based on dollars denied were:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

65.63%

5D164/5H164

No Documentation of Medical Necessity

21

15.63%

5D169/5H169

Services Not Documented

5

6.25%

5D165/5H165

No Physician Certification/Recertification

2

6.25%

5D199/5H199

Billing Error

2

6.25%

5D920/5H920

The Recommended Protocol Was Not Ordered and/or Followed

2

North Carolina Results
A total of eight claims were reviewed, with two of the claims either completely or partially denied. This resulted in a claim denial rate of 25.0 percent. The total dollars reviewed were $1,425.87, of which $307.40 were denied, resulting in a charge denial rate of 21.56 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied were:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

50.0% 5D199/5H199 Billing Error 1

50.0%

5D165/5H165

No Physician Certification/Recertification

1

South Carolina Results
A total of 17 claims were reviewed, with 13 of the claims either completely or partially denied. This resulted in a claim denial rate of 76.47 percent. The total dollars reviewed were $5,953.85, of which $3,136.54 were denied, resulting in a charge denial rate of 52.68 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied were:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

92.31%

5D164/5H164

No Documentation of Medical Necessity

12

7.69%

5D199/5H199

Billing Error

1

Virginia Results
A total of 23 claims were reviewed, with 11 of the claims either completely or partially denied. This resulted in a claim denial rate of 47.83 percent. The total dollars reviewed were $8,934.76, of which $1,459.43 were denied, resulting in a charge denial rate of 16.33 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied were:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

45.45%

5D169/5H169

Services Not Documented

5

27.27%

5D164/5H164

No Documentation of Medical Necessity

3

18.18%

5D920/5H920

The Recommended Protocol Was Not Ordered and/or Followed

2

9.09%

5D165/5H165

No Physician Certification/Recertification

1

West Virginia Results
A total of six claims were reviewed, with six of the claims partially denied. This resulted in a claim denial rate of 100.0 percent. The total dollars reviewed were $735.61, of which $628.14 were denied, resulting in a charge denial rate of 85.39 percent. The top denial reason was identified, and the number of occurrences based on dollars denied were:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

100%

5D164/5H164

No Documentation of Medical Necessity

6

Denial Reasons and Prevention Recommendations

5D164/5H164 — No Documentation of Medical Necessity

Reason for Denial
This claim was denied because the documentation submitted does not support the medical necessity of the service reviewed. The records did not contain any covered condition/indication, symptomology or diagnostic results that would support the service was reasonable and necessary for the treatment of the beneficiary.

How to Avoid This Denial

  • Submit all documentation related to the services billed which support the medical necessity of the services. Documentation should support:
    • A covered indication or condition for the service billed
    • A physician/NPP is managing the care of the covered indication or condition
    • Any medical history that supports a need for the service
    • Any diagnostic results or symptomology that supports a need for the service
  • A legible physician or nonphysician provider (NPP) signature is required on all documentation necessary to support medical necessity
  • Use the most appropriate ICD-10-CM codes to identify the beneficiary’s medical diagnosis

More Information

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 This 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
  • Ensure that the documentation is complete with proper authentication and the signature is legible

More Information

  • Code of Federal Regulations, 42 CFR – Sections 410.32 and 424.5
     

5D165/5H165 — No Physician Certification/Recertification

Reason for Denial
For outpatient therapy 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 This Denial

  • The plan of care must be complete and valid for the certification to be valid
  • The physician/NPP signature on the certification must be legible
  • 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 physician/NPP signature on the certification must be legible for the certification to be valid
  • If certification is provided on a separate document other than the actual plan of care, there must be documentation to support the certifying physician/NPP had access to the plan of care for review. This can be a statement on the document for the physician/NPP, a fax log showing where the plan of care was forwarded to the physician/NPP, or a note in the therapy record indicating the plan of care was forwarded to the physician/NPP.

More Information

  • 42 (CFR) Code of Federal Regulations, Sections 410.61 and 424.24
  • CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220 (PDF, 1.55 MB)
  • Palmetto GBA Local Coverage Determinations
    • Outpatient physical therapy
    • Outpatient occupational therapy
    • Outpatient speech language pathology
  • CMS Internet-Only Manual, Pub 100-8, Medicare Program Integrity Manual, Chapter 3, Section 3.4.1.1, D, Signature Requirements (PDF, 652.50 KB)
     

5D199/5H199 — Billing Error

Reason for Denial
The services billed were not covered because the documentation provided did not support the claim as billed by the provider.

How to Avoid This Denial
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 was rendered, and the dates of service billed.

More Information

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 This 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 medical history documented prior to the DOS and signed by the physician or appropriate nonphysician provider to include:
    • Clear indication of the diagnosis
    • Clinical signs and symptoms
    • Prior treatment and response as applicable
    • Stage of treatment as applicable 
  • Ensure the service was provided per the coverage guidelines for the service
  • Documentation of administration

More Information

56900 — Auto Deny — Requested Records Not Submitted Timely 

Reason for Denial
The services billed were not covered because the documentation was not received in response to the Additional Documentation Request (ADR) and therefore, we were unable to determine the medical necessity of the service billed. The provider has 45 days from the date the ADR was generated to respond with medical records. If less than 120 days after denial notification on the remittance advice, submit records to the contractor requesting records at the address listed on the original Additional Development Request (ADR) to request reopening. Do not resubmit the claim.

How to Avoid This Denial

  • Be aware of the Additional Development Request (ADR) date and the need to submit medical records within 45 days of the ADR date
  • Submit the medical records as soon as the Additional Development Request (ADR) is received
  • Monitor the status of your claims in Direct Data Entry (DDE) and begin gathering the medical records as soon as the claim goes to the location of SB6001
  • Return the medical records to the address on the Additional Development Request (ADR). Be sure to include the appropriate mail code or station number. This ensures that your responses are promptly routed to the Medical Review Department. Fax and electronic data submissions are also accepted as indicated on the Additional Development Request (ADR).
  • Gather all the information needed for the claim and submit it all at one time
  • Attach a copy of the Additional Development Request (ADR) request to each individual claim
  • If responding to multiple Additional Development Requests (ADRs), separate each response and attach a copy of the ADR to each individual set of medical records. Make sure each set of medical records is individually identifiable and bound securely to ensure that no documentation is detached or lost. Do not use paper clips. 
  • Do not mail packages C.O.D.; we cannot accept them

More Information

The Next Steps
The service-specific postpayment medical review edits for CPT Code 97110 — Therapeutic Exercise — in North Carolina, South Carolina, Virginia and West Virginia has been discontinued based on the resumption of Targeted Probe and Educate (TPE).

If you are dissatisfied with a claim determination you have the right to request an appeal. Palmetto GBA encourages you to review the documentation originally submitted, and if you believe you have additional supporting documentation you may include this information with your appeal. For more information related to the appeals process please refer to JM Redetermination: 1st Level Appeal form (PDF, 318 KB). Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 855–696–0705.





Last Updated: 10/21/2021