Postpayment Service-Specific Probe Results for Outpatient Rehabilitation Services: Therapeutic Exercise for July through September 2021

Palmetto GBA performed service-specific postpayment probe review on Outpatient — Rehabilitation Services: 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 90 claims were reviewed with 29 of the claims either completely or partially denied, resulting in an overall claim denial rate of 32.22 percent. The total dollars reviewed was $2,689.82, of which $858.69 was denied, resulting in a charge denial rate of 31.92 percent. Overall, there were a total of nine auto-denied claims in the region. 

North Carolina Results
A total of nine claims were reviewed with one of the claims either completely or partially denied. This resulted in a claim denial rate of 11.11 percent. The total dollars reviewed was $271.26, of which $30.14 was denied, resulting in a charge denial rate of 11.11 percent. The top denial reason were identified, based on dollars denied:

South Carolina Results
A total of 29 claims were reviewed with nine of the claims either completely or partially denied. This resulted in a claim denial rate of 31.03 percent. The total dollars reviewed was $863.06 of which $267.86 was denied, resulting in a charge denial rate of 31.04 percent. The top denial reason identified, based on dollars denied:

Virginia Results
A total of 13 claims were reviewed with none of the claims either completely or partially denied. This resulted in a claim denial rate of 0.00 percent. The total dollars reviewed was $404.61, of which $0.00 was denied, resulting in a charge denial rate of 0.0 percent. There were no denial reasons identified.

West Virginia Results
A total of 39 claims were reviewed with 19 of the claims either completely or partially denied. This resulted in a claim denial rate of 48.72 percent. The total dollars reviewed was $1,150.89, of which $560.69 was denied, resulting in a charge denial rate of 48.72 percent. The top denial reason were identified, based on dollars denied:

Denial Reasons and Prevention Recommendations

NOTMN — Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed

• Ensure that all documentation to support medical necessity of the service billed is submitted for review. This includes original chart notes and any diagnostic, radiological or laboratory results.
• Verify that documentation to support the level of service billed is included. Please refer to Local Coverage Determination (LCD) and National Coverage Determination (NCD) articles on Palmetto GBA's website.
   

NOSIG — Documentation Lacks the Necessary Provider’s Signature

• Verify that all documentation is legibly signed by the rendering physician or nonphysician practitioner
• Verify that electronic signature meets the CMS signature requirements as listed in the article Medicare Medical Records: Signature Requirements, Acceptable and Unacceptable Practices located on our website
• Submit a valid Signature Attestation with any documentation that lacks the correct rending provider's signature. Do not resubmit altered documentation with late added provider signature. This will not be accepted by medical review. For an example of a signature attestation, refer to the article Medicare Medical Records: Signature Requirements, Acceptable and Unacceptable Practices located on our website.
   

NODOC — Documentation Requested for This Date of Service Was Not Received or Was Incomplete; Therefore, We Are Unable to Make a Reasonable and Necessary Determination (as defined under section 1862(a) (1) (a) of the Act) for the Service Billed and This Service Has Been Denied

• Submit all documentation related to the services billed within 45 days of the date on the ADR letter
• Review documentation prior to submission to ensure that the documentation is complete and that all dates of service requested are included
• Include any additional information pertinent to the date of service requested to support the services billed. For example: original chart notes, diagnostic, radiological or laboratory results.
• For claims denied with a M127 or N29 code listed on the remittance advice, be sure to submit all documentation for all dates of service on that claim with a reopen/redetermination request form by fax to JM Part B (803) 699–2427, JJ Part B (803) 870–0139, or RRB Appeals (803) 462–2218
   

NOSIG — Documentation Lacks the Necessary Provider’s Signature

• Verify that all documentation is legibly signed by the rendering physician or nonphysician practitioner
• Verify that electronic signature meets the CMS signature requirements as listed in the article Medicare Medical Records: Signature Requirements, Acceptable and Unacceptable Practices located on our website
• Submit a valid Signature Attestation with any documentation that lacks the correct rending provider's signature. Do not resubmit altered documentation with late added provider signature. This will not be accepted by medical review. For an example of a signature attestation, refer to the article Medicare Medical Records: Signature Requirements, Acceptable and Unacceptable Practices located on our website.
   

The Next Steps
The service-specific postpayment medical review edits for Outpatient – Rehabilitation Services: CPT Code 97110 — Therapeutic Exercise in North Carolina, South Carolina, Virginia and West Virginia has been discontinued based on the resumption of the 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 the JM Part B Appeals web page. Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 855–696–0705.