Medical Review Frequently Asked Questions (FAQs)
Q1. I am on a Targeted Probe and Educate (TPE) review for procedure code 99233. Why are my claims being down coded to procedure code 99232 and 99231?
A1. Per the Current Procedural Terminology (CPT) book procedure code 99233 must meet the following criteria: Subsequent hospital care per day for the evaluation and management of patient which requires at least 2 of these 3 key components:
- A detailed history
- A detailed examination
- Medical decision making of high complexity
Usually the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient hospital floor or unit.
Also, per the Internet Only Manual (IOM). Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. If 99233 is being billed, make sure the criteria listed is met.
Q2. How do I know if I have enough time to send my TPE claim in?
A2. It may be helpful to use the Reopening Timeliness Calculator.
Q3. Who is considered qualified personnel to provide physical therapy?
A3. Per the Internet Only Manual (IOM), Publication (Pub) 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220A, qualified personnel is "staff (auxiliary personnel) who have been educated and trained as therapists and qualify to furnish therapy services only under direct supervision incident to a physician or NPP. Qualified personnel may or may not be licensed as therapists but meet all of the requirements for therapists with the exception of licensure." Additionally, per the IOM, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 230.5 has qualifications of auxiliary personnel. It states for therapy services to appropriately be billed incident to a physician's/NPP's service, they are subject to the same requirements as therapy services that would be provided by a physical therapist. The only exception is therapy services performed incident to, the qualified personnel who performs the services does not need a license to practice therapy, unless required by state law. Qualified personnel must meet all other requirements of a physical therapist, except licensure. For more information, please refer to the IOM, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 220-230.
Q4. How long do I have to wait for a claim decision (payment/denial) before rebilling the service?
A4. Providers should allow a minimum of 30 days from the first claim submission before resubmitting the claim. This allows time for the claim to process through the Medicare claim system. An exact duplicate is a claim or claim line that exactly matches another claim or claim line that has already been billed. Suspect duplicates are claims or claim lines that contain closely aligned elements sufficient to suggest that duplication may be present. Information on the claim elements that make up an exact duplicate and suspected duplicate is in the Medicare Claims Processing Manual (Pub. 100-04), Chapter 1, Section 120 - Detection of Duplicate Claims.
If claim documentation is requested for review, allow 60 - 90 days before resubmitting the claim. This allows time for gathering and submitting the records, review of the documentation and processing of the claim. Duplicate billing should be avoided as it may cause a delay in the payment/denial of a claim. Additional information, including how to check claim status is located on the Duplicate Claim/Submission page of the Noridian Medicare website.
Q5. Who can provider physical therapy services and bill incident to a physician?
A5. Per the Social Security Act, Section 1862(a)(20), payment made for therapy services billed by a physician/NPP only if the service meets the standards and conditions (other than licensing) that would apply to a therapist. Per the Internet Only Manual (IOM), Publication (Pub) 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 230.5, "Therapy services appropriately billed incident to a physician's/NPP's service shall be subject to the same requirements as therapy services that would be furnished by a physical therapist," with the exception of a license to practice therapy unless required by the state. The person who furnishes the therapy services to a beneficiary must be a graduate of a training program, regardless of any state licensing that allows other health professional to provider therapy services. Medicare is authorized to only pay for services provided by those trained specifically in physical therapy. "That means that the services of athletic trainers, massage therapists, recreation therapists, kinesiotherapists, low vision specialists or any other profession may not be billed as therapy services." Services provided by physical therapy assistants (PTA) may not be billed incident to a physician's/NPP's service. However, if a physical therapist (PT) and PTA are both employed in a physician's office, the services provided by the PTA and directly supervised by the PT, may be billed by the physician group as PT services using the PIN/NPI of the enrolled PT. If a physical therapist is not enrolled, Medicare will not pay for services of the PTA billed incident to a physician's service. Additionally, for therapy services provided and billed incident to a physician/NPP must also meet the requirements in IOM, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 60. For more information, please refer to the IOM, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 60 and 230.
Last Updated Mar 30, 2020