Top Denial Reasons

• Failure to Return Records
• Documentation submitted was incomplete and/or insufficient
• Services Billed Not Supported
• Therapy Time: Not Appropriately Documented
• Certification for Therapy and/or Plan or Care: Not Submitted or Signed
• Progress Report after 10th Visit: Not Submitted or Signed
• Treatment Encounter: Not Submitted
• The documentation submitted is not legible.
• The documentation submitted did not include a valid signature and/or credentials.

Educational Resources

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

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.”

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 Coding

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).

Progress Reports

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.

Refer to:

• 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

Treatment Encounter Note Documentation

A treatment encounter note is required to include two-time elements: the total time-based treatment minutes and the total treatment minutes. The total treatment minutes includes both time spent providing time based and untimed code services. The total treatment minutes do not include time for services that are not billed. For Medicare purposes it is not required that the unbilled services that are not part of the total treatment minutes be recorded, although they may be included voluntarily to provide an accurate description of the treatment. The specific amount of time for each intervention and/or procedure provided may also be recorded, but it is not required.

Treatment encounter notes must include:

• Date of treatment
• Identification of each specific intervention/modality to support billing
• Legible signatures with professional credential of qualified staff
• Total treatment minutes for the session, including minutes for timed and untimed code services

Total treatment minutes for the session do not include time for services that are not billable (e.g., rest periods, independent gym activities, patient changing clothing, waiting for/set-up of equipment).

The following are examples to help clarify appropriate documentation requirements:

• Example 1: A patient is seen and treated for 50 minutes. Services completed included therapeutic exercises for 40 minutes and a cold pack for 10 minutes. The total treatment time should be documented as 50 minutes and the total timed code treatment should be documented as 40 minutes supporting the billing for 3 units for Current Procedural Terminology (CPT®) code 97110.
• Example 2: A patient is seen and treated for 45 minutes. Services completed include an evaluation for 30 minutes and therapeutic exercises for 15 minutes. The total treatment time should be documented as 45 minutes and the total timed code treatment should be documented as 15 minutes, which would support billing of CPT® 97162 for 1 unit and CPT® 97110-1 unit.
• Example 3: A patient is seen and treated for 40 minutes. Services completed included therapeutic exercises for 22 minutes, manual therapy for 8 minutes and ultrasound for 10 minutes. The total treatment time should be documented as 40 minutes and the total timed code treatment should be documented as 40 minutes, which would support billing of CPT® 97110-1 unit and 97035-1 unit.

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

Illegible Records

The pre-payment review process involved analysis of data documented in your medical records. Your medical notes were difficult to read. Please keep in mind that the primary purpose of medical documentation is to ensure that the patient's treatment is recorded for quality of care and continuity of appropriate patient treatment. Many records can be read or interpreted only by the physician who wrote them. This hampers patient care by colleagues, consultants, or by office staff. It also complicates transfer of information to insurance companies or other agencies when the patient seeks reimbursement of services. It is therefore important that your notes are written legibly.

Documentation needs to be legible. Section 1833(e), Title XVIII of the Social Security Act states:

“[n]o payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.”

Signature Requirements (AMB1G, AMB4B, AMB4D, AMB4E)

The Internet-Only Manual (IOM) also outlines Medicare signature requirements in the Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.3.2.4. The IOM states:

“For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a handwritten or electronic.”

Examples of acceptable signatures are also located within this manual which may be accessed at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c03.pdf.