The Jurisdiction F, Part B Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of CPT® 97530 - Therapeutic Activities. The quarterly edit effectiveness results from October 1, 2019 through December 31, 2019 are as follows:

Top Denial Reasons

• Failure to return records
• Documentation did not support a Plan of Care (POC) that was certified/signed by the physician or non-physician practitioner
• Documentation did not clearly reflect total direct and indirect time

Educational Resources

• CMS Internet Only Manual (IOM), Publication 100-02, Chapter 15, Section 220-230
• CMS IOM, Publication 100-04, Chapter 5
• Outpatient Therapy Documentation Requirements
• Medical Necessity of Therapy Services
• How to Respond to ADR

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."