Postpayment Service-Specific Probe Results for Therapeutic Exercise for January Through March 2021

Published 05/18/2021

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 January through March 2021, are presented in this article.

Cumulative Results
A total of 1,113 claims were reviewed in North Carolina, South Carolina, Virginia and West Virginia combined. Of the claims reviewed, 225 of the claims were either completely or partially denied, resulting in an overall claim denial rate of 20.22 percent. The total dollars reviewed was $317,473.53, of which $31,019.86 was denied, resulting in a charge denial rate of 9.77 percent. Overall, there was a total of 110 auto-denied claims in the region. 

North Carolina Results
A total of 399 claims were reviewed, with 46 of the claims either completely or partially denied. This resulted in a claim denial rate of 11.53 percent. The total dollars reviewed was $107,135.86, of which $5,173.44 was denied, resulting in a charge denial rate of 4.83 percent. The top denial reasons identified, and number of occurrences based on dollars denied are:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

41.30%

5D199/5H199

Billing Error

19

28.26%

5D165/5H165

Not Accepted Standard Medical Practice

13

15.22%

5D164/5H164

No Documentation of Medical Necessity

7

6.52%

5D920/5H920

The Recommended Protocol Was Not Ordered and/or Followed

3

4.35%

5D151/5H151

Units Billed More Than Ordered

2

South Carolina Results
A total of 158 claims were reviewed, with 36 of the claims either completely or partially denied. This resulted in a claim denial rate of 22.78 percent. The total dollars reviewed was $52,745.12, of which $6,268.01 was denied, resulting in a charge denial rate of 11.88 percent. The top denial reasons identified, and number of occurrences based on dollars denied are:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

38.89%

5D199/5H199

Billing Error

14

22.22%

5D165/5H165

Not Accepted Standard Medical Practice

8

16.67%

5D164/5H164

No Documentation of Medical Necessity

6

8.33%

5D169/5H169

Services Not Documented

3

8.33%

5D920/5H920

The Recommended Protocol Was Not Ordered and/or Followed

3

Virginia Results
A total of 441 claims were reviewed, with 100 of the claims either completely or partially denied. This resulted in a claim denial rate of 22.68 percent. The total dollars reviewed was $127,628.01, of which $13,426.81 was denied, resulting in a charge denial rate of 10.52 percent. The top denial reasons identified, and number of occurrences based on dollars denied are:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

34.00%

5D164/5H164

No Documentation of Medical Necessity

34

24.00%

5D165/5H165

Not Accepted Standard Medical Practice

24

17.00%

5D169/5H169

Services Not Documented

17

10.00%

5CFSG/5FFSG

Partially or Fully Denied Due to a Missing or Illegible Signature

10

9.00%

5D199/5H199

Billing Error

9

West Virginia Results
A total of 115 claims were reviewed, with 43 of the claims either completely or partially denied. This resulted in a claim denial rate of 37.39 percent. The total dollars reviewed was $29,964.54, of which $6,151.60 was denied, resulting in a charge denial rate of 20.53 percent. The top denial reasons identified, and number of occurrences based on dollars denied are:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

27.90%

5D164/5H164

No Documentation of Medical Necessity

12

18.60%

5D162/5H162

Services Not Covered for Diagnosis

8

18.60%

5D169/5H169

Services Not Documented

8

13.95%

5D165/5H165

Not Accepted Standard Medical Practice

6

13.95%

5D199/5H199

Billing Error

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 or 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 or 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


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 or 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 or 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 or NPP had access to the plan of care for review. This can be a statement on the document for the physician or NPP, a fax log showing where the plan of care was forwarded to the physician or NPP, or a note in the therapy record indicating the plan of care was forwarded to the physician and/or nonphysician.

More Information

  • 42 (CFR) Code of Federal Regulations, Sections 410.61 and 424.24
  • CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220 
  • LCDs, NCDs, Coverage Articles
    • Outpatient physical therapy
    • Outpatient occupational therapy
    • Outpatient speech language pathology
  • CMS Internet-Only Manual (IOM), Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.4.1.1, D. Signature Requirements (PDF)


5D162/5H162 — No Valid Plan of Care

Reason for Denial
For outpatient therapy 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 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 This 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 must include:
    • A diagnosis or disabling conditions the services are intended to help with
    • Individualized goals, specific to the beneficiaries disabling condition
    • The type, amount, duration and frequency of the specific therapy service
    • Date that plan of care was developed
    • Signature of person who developed the plan of care
  • The plan of care must be kept up to date and accurately reflect the course of treatment being provided to the beneficiary. Changes/updates to the POC must be signed, same as the original development of the POC. The physician, NPP or treating therapist can make and sign these changes. 

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 
  • Clear and complete documentation of administration signed by the person providing the service
  • Ensure the service was provided per the coverage guidelines for the service
  • Documentation of administration 

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.


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
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 was rendered, and the dates of service billed

More Information


5D151/5H151 — Units Billed More Than Ordered

Reason for Denial 
The medical record provided for the outpatient service did not support the number of units billed on the claim. Per the documentation more units were billed than provided.

How to Avoid This Denial
Under the Outpatient Prospective Payment System (OPPS), when HCPC code reporting is required the number of times the service or procedure was performed or the amount of the service used must also be accurately reported in the service units. 

  • For time-based general outpatient services, make sure the start and end time, or total length of the service is documented clearly in the record
  • For other general outpatient services, make sure the amount of the service is documented clearly in the record 
  • When reporting drugs or biologicals make sure the amount of the drug given is clearly documented and properly converted into units when submitted for payment
  • For outpatient therapy services, make sure the timed treatment minutes for the timed services provided are documented clearly in the record

More Information


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 This 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 either 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 and/or ordered be authenticated by the author. The method used shall be a handwritten or an electronic signature. Stamp signatures are not acceptable.

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 will be continued based on moderate charge denial rates and medium to high impact severity errors. If significant billing aberrancies are identified, provider-specific review may be initiated.

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 Redetermination: 1 Level Appeal form. Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 855–696–0705.