Postpayment Service-Specific Probe Results for Rehabilitation Services: Therapeutic Exercises for April through June 2021

Postpayment Service-Specific Probe Results for Rehabilitation Services: Therapeutic Exercises in North Carolina, South Carolina, Virginia and West Virginia for April through June 2021

Palmetto GBA performed service-specific postpayment probe review on CPT Code 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 April through June 2021, are presented here.

Cumulative Results 
A total of 268 claims were reviewed, with 123 of the claims either completely or partially denied, resulting in an overall claim denial rate of 45.90 percent. The total dollars reviewed was $8,694.53, of which $3,714.70 was denied, resulting in a charge denial rate of 42.72 percent. Overall, there were no auto-denied claims in the region.

North Carolina Results
A total of 191 claims were reviewed, with 90 of the claims either completely or partially denied. This resulted in a claim denial rate of 47.12 percent. The total dollars reviewed was $6,352.08, of which $2,712.67 was denied, resulting in a charge denial rate of 42.71 percent. The top denial reasons identified and number of occurrences based on dollars denied are:

South Carolina Results
A total of 34 claims were reviewed, with 18 of the claims either completely or partially denied. This resulted in a claim denial rate of 52.94 percent. The total dollars reviewed was $1,011.84, of which $535.68 was denied, resulting in a charge denial rate of 52.94 percent. The top denial reasons identified and number of occurrences based on dollars denied are:

Virginia Results
A total of 41 claims were reviewed, with 15 of the claims either completely or partially denied. This resulted in a claim denial rate of 36.59 percent. The total dollars reviewed was $1,271.59, of which $466.35 was denied, resulting in a charge denial rate of 36.67 percent. The top denial reason identified and number of occurrences based on dollars denied are:

West Virginia Results
A total of 2 claims were reviewed, with none of the claims either completely or partially denied. This resulted in a claim denial rate of zero percent. The total dollars reviewed was $59.02 of which $0.00 was denied, resulting in a charge denial rate of zero percent. There were no denial reasons identified.

Denial Reasons and Prevention Recommendations

BILER — Claim Billed in Error Per Provider

• Prior to billing claims, review the information to determine that the correct information is listed in the appropriate fields
• For all claims previously billed and denied by medical review, do not resubmit the claims. If you disagree with the decision from medical review, you must submit the appropriate documentation with a completed redetermination request form to the Appeals department. This information can be sent by fax to JM Part B Appeals (803) 699–2427, JJ Part B Appeals (803) 870–0139, or RRB Appeals (803) 462–2218.
• If documentation indicates that both an NPP and a physician performed the service, and the claim is billed under the physician’s NPI, the billing physician must sign the record. Additionally, the documentation must include a statement that the billing provider had face-to-face contact with the patient and performed a substantive portion of the E/M visit. (A substantive portion of the E/M visit includes at least one of the three key components: history, exam, or medical decision-making.)
• If documentation occurs in a teaching environment, review the documentation to ensure that the billing provider has provided a teaching attestation and a signature
   

DNSRP — Documentation Not Signed by the Rendering Provider

• Verify that all documentation is legibly signed by the correct 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 a 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.
   

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 our website for links to applicable LCD and NCD articles
   

The Next Steps
The service-specific targeted medical review edits for Rehabilitation Services: CPT Code 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 the JM Redetermination: 1st Level Appeal form (PDF, 237 MB). Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 855–696–0705.