Medical Review Frequently Asked Questions (FAQs)

Q1.  How do I know how many units to bill for my physical or occupational therapy claims? My therapist saw the beneficiary for 25 minutes of procedure code 97110 and 40 minutes of 97112.
A1. Use the Medicare Number of Minutes chart to determine the units to bill for therapy services.
One unit:  >8 minutes through 22 minutes.
Two units: >23 minutes through 37 minutes.
Three units >38 minutes through 52 minutes.
Four units: >53 minutes through 67 minutes.
Five units: >68 minutes through 82 minutes.
Six units: >83 minutes through 97 minutes.
Seven units: >98 minutes through 112 minutes.

Q2. What documentation should be submitted to support medical necessity when billing for the procedure code 64405: Injection(s), anesthetic agent(s) and/or steroid; greater occipital nerve?
A2. The Local Coverage Determination (LCD) is for chronic pain, and it states, “Prior to blockade, all patients with pain complaints require an evaluation that includes, at a minimum, an assessment of the source of the pain and treatment of any underlying pathology. Evaluation must be documented in the patient’s records. In addition, those patients who do not respond to injections or otherwise continue with persistent or poorly responsive pain should be referred for a multi-disciplinary or other collaborative comprehensive evaluation.” Therefore, documentation submitted must support an evaluation that includes an assessment of the source of the pain and treatment of any underlying pathology. This may include the initial encounter related to their chronic pain complaint. An assessment and evaluation would be a complete overview of the patient’s chronic pain complaint. An assessment may include a comprehensive assessment of the neurological system affected. An evaluation may include diagnostic testing. Other information supported in the patient’s medical record maybe included in the submitted documentation to help support medical necessity including referring if the patient is having a poor response to the injections. Please see LCD: L35456.

Q3. My office was notified that I have a Targeted Probe and Educate (TPE) review. How do I know what documentation to send in for this review?
A3. The documentation requirements page on the Noridian Website lists information about what documentation to send in if records are requested for a TPE review for a specific service or specialty. Link: Documentation Requirements. Additionally, for each claim developed for records there will be an Additional Documentation Request (ADR) letter sent. The ADR letter will have a listing of what documentation to send. Link: How to Read an ADR.

Q4. Is there information I can send to the certifying physician to obtain the required medical records for Repetitive, Scheduled Non-emergent Ambulance Transport?
A4. The CMS Prior Authorization and Pre-Claim Review Initiatives for Repetitive, Scheduled Non-emergent Ambulance Transport (RSNAT) website has a pdf you may choose to share with physicians and other entities to help ensure that you obtain the necessary documentation in a timely manner.

Q5. How do I know what documentation is required for RSNAT services?
A5. Prior authorization does not create new clinical documentation requirements. Instead, it requires the same information that is already required to support Medicare payment, just earlier in the process. Documentation requirements for RSNAT may be located on the Prior Authorization for Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) page.


Last Updated Wed, 30 Mar 2022 14:41:59 +0000