Pre-Payment Review Results for Neuromuscular Reeducation for January to March 2025

Pre-Payment Review Results for Neuromuscular Reeducation for Targeted Probe and Educate (TPE) for January through March 2025

The Centers for Medicare & Medicaid Services (CMS) implemented the TPE process for Current Procedural Terminology (CPT^®) code 97112 for Neuromuscular Reeducation. The reviews with edit effectiveness are presented here for North Carolina, South Carolina, Virginia and West Virginia.

Cumulative Results

Probe Two Findings

Risk Category

The risk categories for CPT^® code 97112 for Neuromuscular Reeducation are defined as:

Figure 1. Risk Category.

Top Denial Reasons

Denial Reasons and Recommendations

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 documentation must support the plan of treatment was established and signed by the physician prior to the initiation of therapy services
• 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 or NPP.
• The documentation must show evidence of delayed certification or attempts to obtain certification from the physician / NPP or reason for delayed/lapsed (re)certification

References

• 42 (CFR) Code of Federal Regulations, Sections 409.17, 410.61, 410.61(B), 424.11(d)(3), and 424.24
• CMS Internet-Only Manual (IOM), Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 220, 220(A), 220.1.2A, 220.1.3 A, 220.1.3 B-D, and 220.1.3 C-D (PDF)
• Palmetto GBA Local Coverage Determinations
  • Outpatient Physical Therapy
  • Outpatient Occupational Therapy
  • Outpatient Speech Language Pathology 
• CMS IOM, Pub. 100-8, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4 — Signature Requirements (PDF)
   

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 billed is documented in the record
  • Any medical history that supports a need for the service
  • Any diagnostic results or symptomology that supports a need for the service
• Legible documentation
• Submit all documentation to support ongoing skills of a qualified therapist were required to complete the treatment and that the initiation of therapy treatment services were medically necessary
• ABN is valid, complete, and submitted in the record if applicable
• 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
• Submit treatment note documentation that contains date of treatment, description of modality/procedure to support accurate billing, total treatment minutes/ total timed code treatment minutes and signature of qualified professional
• Documentation to include the therapy discharge note and summary
• All documentation submitted is legible

References

• 42 CFR, Sections 409.44(c)(2), 410.60(c)(2)
• Social Security Act (SSA) — Section 1862(a)(1)(A)
• CMS IOM, Pub. 100-02, Medicare Program Integrity Manual, Chapter 15, Section 220.2, 220.2A, 220.2B, 230.1C and 230.2C (PDF)
• CMS IOM, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4, 3.4.1.3, 3.6.2.1, 3.6.2.2 (PDF)
   

Education
Palmetto GBA offers providers selected for TPE an individualized education session to discuss each claim denial. This is an opportunity to learn how to identify and correct claim errors. A variety of education methods are offered such as webinar sessions, web-based presentations or teleconferences. Other education methods may also be available. Providers do not have to be selected for TPE to request education. If education is desired, please complete the Education Request Form. 

Next Steps
Providers found to be non-compliant (major risk category/denial rate of 21–100 percent) 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 percent) at the completion of TPE Probe 2 will advance to Probe 3 of TPE after at least 45 days from completing the 1:1 post-probe education call date.