Therapeutic Procedure Re-Evaluation Targeted Probe and Educate Review Results - JE Part B
Therapeutic Procedure Re-Evaluation Targeted Probe and Educate Review Results
The Jurisdiction E, Part B Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of CPT® 97164 - Therapeutic Procedure Re-Evaluation. The quarterly edit effectiveness results from January 1, 2020 through March 31, 2020 are as follows:
Top Denial Reasons:
- Services Billed Not Supported
- Therapy Time: Not Appropriately Documented
- Certification for Therapy and/or Plan or Care: Not Submitted or Signed
- ABN is invalid, incomplete or missing
- Progress Report after 10th Visit: Not Submitted or Signed
- How to Respond to ADR
- Signature Requirement Questions and Answers
- Required Documentation
- Services Billed Not Supported
- Therapy Time Progress Report and Certification
- Therapy Certification Progress Report and Time
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).
Time-based services are billed only for the total time-based minutes that the service was provided. If only one time-based service is provided for less than 8 minutes during a single therapy visit, then the service should not be billed. However, if during a single therapy visit 8 minutes of a time-based service is provided in addition to another time-based service, then the total combined minutes for all the time-based services is used to determine accurate billing of the total time-based unit(s).
Additionally, if 2 services are performed, but the total number of time-based minutes allows 3 units to be billed, it is appropriate to bill 3 units based on the total time-based minutes, assigning the additional unit to the service that took the most amount of time.
The expectation remains that the provider’s direct treatment time for each time-based unit billed will average 15 minutes. If a provider is consistently billing less than 15 minutes for a unit, this may be highlighted for review.
Refer to: Internet Only Manual (IOM), Publication 100-04, Medicare Claims processing Manual (MCPM), Chapter 5, Section 20.2.
Timed Code Units
When billing timed codes for outpatient therapy, billing should be based solely on the total timed code treatment minutes provided. If only one timed code service is provided for less than 8 minutes during a single therapy visit, then the service should not be billed. However, if during a single therapy visit 8 minutes of a timed code service is provided in addition to another timed code service, then the total combined minutes for all of the timed code services is used to determine accurate billing of the total timed code unit(s). Additionally, if 2 timed code services are performed, each individually spending 1 unit worth of time, but the total timed code minutes allows 3 units to be billed, then it would be appropriate to bill 3 units based on the total timed code minutes, assigning the additional unit to the service that took the most amount of time.
The expectation remains, however, that a provider’s direct treatment time for each timed code unit will average 15 minutes. If a provider is consistently billing less than 15 minutes for a unit, this may be highlighted for review.
The following are examples to help clarify appropriate billing practices based on total timed code treatment minutes for therapy services:
Example 1 - The treatment encounter note supports:
- 30 minutes initial evaluation, Current Procedural Terminology (CPT®) 97162
- 5 minutes therapeutic exercises, CPT® 97110
- When the visit includes both untimed and timed-based services, the documentation needs to clearly indicate that the total time of the visit was 35 total visit minutes. This documentation supports coding of 1 unit for CPT® 97162 and no coding for CPT® 97110 since the required minimum 8 minute threshold is not met.
Example 2 - The treatment encounter note supports:
- 20 minutes of manual therapy, CPT® 97140
- 20 minutes of therapeutic exercises, CPT® 97110
- The total timed code treatment time is 40 minutes, which allows 3 units to be billed (3 units = 38-52 minutes). Even though each service is performed for only 1 unit of time individually, the total time allows for 3 units. Since both services are performed for the same amount of time, choose 1 service to bill 2 units and the other service is billed for 1 unit.
Example 3 - The treatment encounter note supports:
- 35 minutes of manual therapy, CPT® 97140
- 7 minutes of gait training, CPT® 97116
- Total time-based treatment time is 42 minutes, which allows for 3 units to be billed. The first 30 minutes counted towards CPT® 97140 which supports 2 full units (per the 15 minute relative work value for each unit). The remaining time spent on CPT® 97140 (5 minutes) compared to the time spent on CPT® 97116 (7 minutes) and the service that took more time is the service that should receive the remaining 1 unit. The documentation supports 2 units of CPT® 97140 and 1 unit of CPT® 97116
Example 4 - The treatment encounter note supports:
- 25 minutes of therapeutic exercises, CPT® 97110
- 24 minutes of therapeutic activities, CPT® 97530
- Total timed-based treatment time is 49 minutes, which allows for 3 units to be billed. Therefore, even though each individual service is performed for 2 units worth of time, the total time allows for only 3 units. The documentation supports 2 units of CPT® 97110 and 1 unit of CPT® 97530, billing more timed units to the service that took the most time.
Example 5 - The treatment encounter note supports:
- 20 minutes of manual therapy, CPT® 97140
- 10 minutes of therapeutic exercises, CPT® 97110
- 10 minutes of gait training, CPT® 97116
- 8 minutes of ultrasound, CPT® 97035
- Total time-based treatment time is 48 minutes, which allows for 3 units to be billed. Therefore, even though each individual service is performed for 1 unit worth of time, the total time allows for only 3 units. This documentation supports 1 unit each of CPT® 97140, 97110, 97116. The ultrasound is not able to be billed, as the total units that can be billed are constrained by the total timed code treatment minutes. (In order to bill 4 units, there must be 53-67 total time-based treatment minutes).
Example 6 - The treatment encounter note supports:
- 10 minutes of vasopneumatic device, CPT® 97016
- 21 minutes of therapeutic exercises, CPT® 97110
- 9 minutes of manual therapy, CPT® 97140
- The total treatment time is 40 minutes and the total time-based treatment is 30 minutes. This documentation supports 1 unit of CPT® 97016, 1 unit of CPT® 97110 and 1 unit of CPT® 97140.
Refer to: Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual (MCPM), Chapter 5, Section 20.2.
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).
An Advanced Beneficiary Notice of Noncoverage (ABN) must be issued when the health care provider (including independent laboratories, physicians, practitioners and suppliers) believes that Medicare may not pay for an item or service because of medical necessity, frequency limitations, discontinued services, experimental and investigational, and not safe or proven effective.
It gives a beneficiary the opportunity to make an informed decision prior to the procedure or service being rendered to decide whether to receive the service and accept financial responsibility if denied by Medicare and serves as proof that the beneficiary had knowledge prior to receiving the service that Medicare might not cover. If the provider does not deliver a valid ABN to the beneficiary when required, the beneficiary cannot be billed for the service and the provider may be held financially liable.
An ABN must not be used for all services and is not required for services that are statutorily excluded. Such as: vitamins, nutritional counseling, x-rays, office visit, and therapy.
A single ABN is acceptable when it identifies all items/services and duration of period of treatment, no treatment changes have occurred, and services have not been added/deleted. If there are ANY changes, a new ABN is required.
Medical Necessity is defined as services that are reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member and are not excluded under another provision of the Medicare Program.
The ABN must be completed in its entirety for it to be valid. An interactive tutorial is available on the CMS website at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ABN-Tutorial/formCMSR131tutorial111915f.html.
The progress report(s) must provide justification of medical necessity for continued treatment and supports that required therapy services are complex and sophisticated such that they can only be safely and effectively provided by or under the supervision of a qualified therapist. The minimum progress report period shall be at least once every 10 treatment days which includes assessment of the patient’s response to therapy services, plans for continued treatment or treatment revisions, updates to short or long-term goals and objective functional assessment. If each element required in a progress report is included in the treatment encounter notes, at least once during the progress reporting period, then a separate progress report is not required. Without the elements of the progress report documented in the medical record, medical necessity is difficult to establish.
Physical therapy assistants (PTAs) or occupational therapy assistants (OTAs) may write elements of the progress report dated between qualified therapist reports. Reports written by assistants are not complete progress reports. The qualified therapist must write a progress report during each progress report period regardless of when the assistant writes other reports.
- Noridian Coverage Article, "Medical Necessity of Therapy Services"
- Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 15, Section 220.3(D), 220-230
Last Updated Mon, 03 Aug 2020 17:24:34 +0000