97110 Therapeutic Exercise Postpayment Results for October to December 2020

Published 03/29/2021

Postpayment Service-Specific Probe Results for Outpatient Therapeutic Exercises in North Carolina, South Carolina, Virginia and West Virginia for October to December 2020

Palmetto GBA performed service-specific post payment probe review on for Outpatient – Rehabilitation Services CPT Codes 97110 – Therapeutic Exercises. This edit was set in North Carolina, South Carolina, Virginia and West Virginia. The results for the probe review for claims processed October to December 2020 are presented here.

Cumulative Results
A total of 82 providers were placed on edit in North Carolina, South Carolina, Virginia and West Virginia combined. A total of 445 claims were reviewed, with 52 of the claims either completely or partially denied, resulting in an overall claim denial rate of 11.69 percent. The total dollars reviewed was $113,540.00 of which $6,736.31 was denied, resulting in a charge denial rate of 5.93 percent. Overall, there was a total of 21 auto denied claims in the region.

North Carolina Results
A total of 39 providers were placed on edit in North Carolina. A total of 252 claims were reviewed, with 21 of the claims either completely or partially denied. This resulted in a claim denial rate of 8.33 percent. The total dollars reviewed was $59,413.98 of which $2,143.24 was denied, resulting in a charge denial rate of 3.61 percent. The top denial reasons identified, based on dollars denied:

Percent of Total Denials  Denial Code  Denial Description
23.81% 5H165 Not Accepted Standard Medical Practice
19.05% 5D164 No Documentation of Medical Necessity
14.29% 5D165 No Certification
9.52% 5H151 Units Billed More Than Ordered
9.52% 5H164 No Documentation of Medical Necessity

In order to provide more specific information about the denial reasons identified above, a second level of detail was obtained during Medical Review. Each claim that is reviewed may contain more than one type of “granular” error finding. The individual error findings shown below are listed in decreasing order of occurrence, grouped according to the major denial categories listed above.

Denial Code  Denial Description Specific “Granular” Denial Findings Number of Occurrences
5H165 Not Accepted Standard Medical Practice No Physician Certification/Re-Certification 5
5D164 No Documentation of Medical Necessity      No Documentation of Medical Necessity 4
5D165 No Certification    No Physician Certification/Re-Certification 3
5H151 Units Billed More Than Ordered     Units Billed More Than Ordered 2
5H164 No Documentation of Medical Necessity No Documentation of Medical Necessity 2


South Carolina Results
A total of 19 providers were placed on edit in South Carolina. A total of 79 claims were reviewed, with seven of the claims either completely or partially denied. This resulted in a claim denial rate of 8.86 percent. The total dollars reviewed was $21,527.48 of which $639.78 was denied, resulting in a charge denial rate of 2.97 percent. The top denial reasons identified, based on dollars denied:

Percent of Total Denials  Denial Code Denial Description
28.57% 5H199 Billing Error
28.57% 5H151 Units Billed More Than Ordered
14.29% 5H169 Services Not Documented
14.29% 5D920 The Recommended Protocol Was Not Ordered and/or Followed
14.29% 5H920 The Recommended Protocol Was Not Ordered and/or Followed    

In order to provide more specific information about the denial reasons identified above, a second level of detail was obtained during Medical Review. Each claim that is reviewed may contain more than one type of “granular” error finding. The individual error findings shown below are listed in decreasing order of occurrence, grouped according to the major denial categories listed above.

Denial Code Denial Description Specific “Granular” Denial Findings Number of Occurrences
5H199 Billing Error Billing Error 2
5H151 Units Billed More Than Ordered Units Billed More Than Ordered 2
5H169 Services Not Documented Services Not Documented 1
5D920 The Recommended Protocol Was Not Ordered and/or Followed The Recommended Protocol Was Not Ordered and/or Followed 1
5H920 The Recommended Protocol Was Not Ordered and/or Followed The Recommended Protocol Was Not Ordered and/or Followed 1


Virginia Results
A total of 20 providers were placed on edit in Virginia. A total of 106 claims were reviewed, with 21 of the claims either completely or partially denied. This resulted in a claim denial rate of 19.81 percent. The total dollars reviewed was $30,698.94 of which $3,702.80 was denied, resulting in a charge denial rate of 19.81 percent. The top denial reasons identified, based on dollars denied:

Percent of Total Denials  Denial Code  Denial Description
47.62% 5H164 No Documentation of Medical Necessity
23.81% 5H169 Services Not Documented
19.05% 5H199 Billing Error
4.76% 5H151 Units Billed More Than Ordered
4.76% 5D164 No Documentation of Medical Necessity 

In order to provide more specific information about the denial reasons identified above, a second level of detail was obtained during Medical Review. Each claim that is reviewed may contain more than one type of “granular” error finding. The individual error findings shown below are listed in decreasing order of occurrence, grouped according to the major denial categories listed above.

Denial Code Denial Description Specific “Granular” Denial Findings Number of Occurrences
5H164 No Documentation of Medical Necessity No Documentation of Medical Necessity 10 
5H169 Services Not Documented Services Not Documented 5
5H199 Billing Error Billing Error 4
5H151 Units Billed More Than Ordered Units Billed More Than Ordered 1
5D164 No Documentation of Medical Necessity No Documentation of Medical Necessity 1


West Virginia Results
A total of four providers were placed on edit in Georgia. A total of eight claims were reviewed, with three of the claims either completely or partially denied. This results in a claim denial rate of 37.50 percent. The total dollars reviewed was $1,899.60 of which $250.49 was denied, resulting in a charge denial rate of 13.19 percent. The top denial reasons identified, based on dollars denied:

Percent of Total Denials  Denial Code  Denial Description
66.67% 5H165 Not Accepted Standard Medical Practice
33.33% 5H164 No Documentation of Medical Necessity

In order to provide more specific information about the denial reasons identified above, a second level of detail was obtained during Medical Review. Each claim that is reviewed may contain more than one type of “granular” error finding. The individual error findings shown below are listed in decreasing order of occurrence, grouped according to the major denial categories listed above.

Denial Code Denial Description Specific “Granular” Denial Findings Number of Occurrences
5H165  Not Accepted Standard Medical Practice No Physician Certification/Re-Certification 2
 5H164 No Documentation of Medical Necessity No Documentation of Medical Necessity 1

 
Denial Reasons and Prevention Recommendations

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 This 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

For more information, refer to:

  • Code of Federal Regulations, 42 CFR — Section 411.15
  • Social Security Act (SSA) — Section 1862(a)(1)(A)
  • Palmetto GBA Local Coverage Determination (LCD), which is available on the Palmetto GBA website
  • National Coverage Determination (NCD), which is available on the Palmetto GBA website
  • CMS Internet-Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4
  • The articles below can be located on the Palmetto GBA website using the Search feature
  • CMS Medicare Learning Network (MLN) Matters article MM6698  — Signature Guidelines for Medical Review Purposes
  • Medicare Medical Records: Signature Requirements Acceptable and Unacceptable Practices

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 re-certification 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

For more information, refer to:

  • 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
  • Palmetto GBA Local Coverage Determinations
  • CMS Manual System, Pub 100-8, Chapter 3, Section 3.4.1.1, D. Signature Requirements

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 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/diagnostic test was rendered, and the dates of service billed

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

For more information, refer to:

  • Code of Federal Regulations, 42 CFR – Sections 410.32 and 424.5
  • This article below can be located on the Palmetto GBA website using the Search feature: “Responding to an Outpatient Therapy Additional Documentation Request (ADR)”

5D151/5H151 — Units Billed More Than Ordered
Reason for Denial

The physician’s orders submitted did not cover all of the units billed.

How to Avoid This Denial
In order to avoid unnecessary denials for this reason, the provider should ensure that the physician’s orders cover all the services to be billed prior to billing Medicare. When responding to an Additional Documentation Request (ADR), ensure that all orders for services billed are included with the medical records.

For further information on the above Medicare coverage issue, references include, but are not limited to, these resources:

  • 42 (CFR) Codes of Federal Regulations, Sections 410.27 and 424.5
  • CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Chapter 17, Sections 90.2

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 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

For further information on the above Medicare coverage issue, references include, but are not limited to, these resources:

  • Medicare Benefit Policy Manual, Publication 100-02: Chapter 15, Section 50
  • Medicare Claims Processing Manual, Publication 100-04: Chapter 17

The Next Steps
The service-specific targeted medical review edits for Rehabilitation Services CPT Codes 97110 – Therapeutic Exercises 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 https://palmettogba.com/palmetto/Mforms.nsf/files/AP-JM-A-1000.pdf/$File/AP-JM-A-1000.pdf?Open.

Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 855–696–0705.