The Jurisdiction E, Part B Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of CPT® 97110 – Therapeutic Procedure Therapeutic Exercise. The quarterly edit effectiveness results from January 1, 2020 through March 31, 2020 are as follows:

Top Denial Reasons

• Failure to Return Records
• Duplicate service previously submitted by the same provider
• Documentation submitted was incomplete and/or insufficient
• Services Billed Not Supported
• Certification for Therapy and/or Plan or Care: Not Submitted or Signed

Educational Resources

• How to Respond to ADR
• Signature Requirement Questions and Answers
• Required Documentation
• Services Billed Not Supported
• Therapy Certification

Education

Failure To Return Records

The Internet-Only Manual (IOM) addresses timeframes for submission of records for pre-payment reviews in the Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.2.3.2.

“When requesting documentation for prepayment review, the MAC and ZPIC shall notify providers that the requested documentation is to be submitted within 45 calendar days of the request. The reviewer should not grant extensions to providers who need more time to comply with the request. Reviewers shall deny claims for which the requested documentation was not received by day 46.”

Duplicate Claims

Duplicate claims are those billed by the same provider for the same patient, same date of service and same Current Procedural Terminology (CPT®)/Healthcare Common Procedure Coding System (HCPCS®) code. It is not appropriate to continually bill a claim that has been denied as a duplicate for the purpose of receiving payment. The only time a claim should be resubmitted to Medicare is when the claim is denied un-processable.
Refer to: Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 120.

Documentation to Support Billing

In order for a claim for Medicare benefits to be valid, there must be sufficient documentation to verify the services were performed, and also the level of care that was required. If there is no documentation or insufficient documentation, then there is no justification for the services, or the level of care billed. Services that are denied based on no documentation are reflected as billing errors.

Refer to: Internet Only Manual (IOM) 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 15, Section 220.3(E).

Plan of Care and Certification/Recertification Requirements

The minimum plan of care requirements includes a) diagnoses; b) long term treatment goals and; c) type, amount, frequency and duration of therapy services. Frequency “refers to the number of times in a week the type of treatment is provided” which can be tapered as necessary. The plan must be established before treatment is begun. Certification requires a dated physician/non-physician practitioner (NPP) signature on the plan of care or some other document that indicates approval of the plan of care.

The format of all certifications and re-certifications and the method by which they are obtained is determined by the individual facility. Initial certification should be obtained as soon as possible after the plan of care is established. Timeliness is met when the initial certification is signed within 30 days of initial treatment under that plan. Recertifications must be signed during the duration of the plan of care or within 90 days, whichever is less. Delayed certifications/recertifications are acceptable without justification for 30 days after they are due. Delayed certification/recertifications may still be satisfied at any later date when the physician/NPP makes a certification accompanied by a reason for the delay.

The physician/NPP certification of the plan of care is good for the duration of the plan of care or for 90 days, whichever is less, i.e. if frequency and duration on a certified plan of care is documented as 2x’s/week x 4 weeks, then that certification is good for 4 weeks (not 90 days).

Treatment beyond the duration certified by the physician/NPP requires that the plan be recertified for the extended duration of treatment. Also, it must be noted that medical necessity documentation (even in instances when the certification/recertification extends beyond 30 days), must be documented every 10 treatment days as per the Progress Report requirements.

Refer to: Internet Only Manual (IOM) 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 15, Sections 220.1.2, 220.1.3, 220.3(D).