The Jurisdiction E, Part B Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of CPT® 97112 – Therapeutic Procedure Neuromuscular Re-education. 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

Educational Resources

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

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

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).