Postpayment Service-Specific Probe Results for Outpatient Rehabilitation Services: Manual Therapy for January through March 2021

Published 09/30/2021

Postpayment Service-Specific Probe Results for Outpatient Rehabilitation Services — Manual Therapy — in Alabama, Georgia and Tennessee for January through March 2021

Palmetto GBA performed service-specific postpayment probe review on Outpatient Rehabilitation Services, CPT® code 97140 – Manual Therapy. This edit was set in Alabama, Georgia, and Tennessee. The results for the probe review, for claims processed January through March, 2021, are presented in this article.

Cumulative Results
A total of 483 claims were reviewed, with 36 of the claims either completely or partially denied, resulting in an overall claim denial rate of 7.45 percent. The total dollars reviewed was $175,969.11, of which $3344.02 was denied, resulting in a charge denial rate of 1.9 percent. Overall, there were a total of 62 auto-denied claims in the region.

Alabama Results
A total of 123 claims were reviewed, with nine of the claims either completely or partially denied. This resulted in a claim denial rate of 7.32 percent. The total dollars reviewed was $38,999.92, of which $663.67 was denied, resulting in a charge denial rate of 1.7 percent. The top denial reasons were identified, based on dollars denied: 

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

33.33%

5D164/5H164

No Documentation of Medical Necessity

3

22.22%

5D169/5H169

Services Not Documented

2

22.22%

5D920/5H920

The Recommended Protocol Was Not Ordered and/or Followed

2

11.11%

5D151/5H151

Units Billed More Than Ordered

1

11.11%

5D199/5H199

Billing Error

1

Georgia Results
A total of 198 claims were reviewed, with 18 of the claims either completely or partially denied. This resulted in a claim denial rate of 9.09 percent. The total dollars reviewed was $75,168.90, of which $1,433.18 was denied, resulting in a charge denial rate of 1.91 percent. The top denial reasons were identified, based on dollars denied:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

44.44%

5D164/5H164

No Documentation of Medical Necessity

8

22.22%

5D169/5H169

Services Not Documented

4

11.11%

5D165/5H165

No Physician Certification/Recertification

2

11.11%

5D162/5H162

No Valid Plan of Care

2

11.11%

5D920/5H920

The Recommended Protocol Was Not Ordered and/or Followed

2

Tennessee Results
A total of 162 claims were reviewed, with nine of the claims either completely or partially denied. This resulted in a claim denial rate of 5.56 percent. The total dollars reviewed was $61,800.29, of which $1,247.17 was denied, resulting in a charge denial rate of 2.02 percent. The top denial reasons were identified, based on dollars denied:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

55.56%

5D165/5H165

No Physician Certification/Recertification

5

11.11%

5D164/5H164

No Documentation of Medical Necessity

1

11.11%

5D151/5H151

Units Billed More Than Ordered

1

11.11%

5D199/5H199

Billing Error

1

11.11%

5D920/5H920

The Recommended Protocol Was Not Ordered and/or Followed

1

Denial Reasons and Prevention Recommendations

5D164/5H164 — No Documentation of Medical Necessity

Reason for Denial
This claim was denied because the documentation submitted does not support the medical necessity of the service reviewed. The records did not contain any covered condition/indication, symptomology or diagnostic results that would support the service was reasonable and necessary for the treatment of the beneficiary.

How to Avoid This Denial

Submit all documentation related to the services billed which support the medical necessity of the services. Documentation should support:

  • A covered indication or condition for the service billed
  • A physician/NPP is managing the care of the covered indication or condition 
  • Any medical history that supports a need for the service 
  • Any diagnostic results or symptomology that supports a need for the service 
  • A legible physician or nonphysician provider (NPP) signature is required on all documentation necessary to support medical necessity
  • Use the most appropriate ICD-10-CM codes to identify the beneficiary’s medical diagnosis

More Information

5D165/5H165 — No Physician Certification/Recertification
Reason for Denial

This claim was denied because the documentation submitted does not support the medical necessity of the service reviewed. The records did not contain any covered condition/indication, symptomology or diagnostic results that would support the service was reasonable and necessary for the treatment of the beneficiary.

How to Avoid This Denial
Submit all documentation related to the services billed which support the medical necessity of the services. Documentation should support:

  • A covered indication or condition for the service billed 
  • A physician/NPP is managing the care of the covered indication or condition 
  • Any medical history that supports a need for the service 
  • Any diagnostic results or symptomology that supports a need for the service 
  • A legible physician or nonphysician provider (NPP) signature is required on all documentation necessary to support medical necessity
  • Use the most appropriate ICD-10-CM codes to identify the beneficiary’s medical diagnosis

More Information

5D169/5H169 — Services Not Documented
Reason for Denial

This claim was partially or fully denied because the provider billed for services/items not documented in the medical record submitted.

How to Avoid This Denial

  • Submit all documentation related to the services billed
  • Ensure that results submitted are for the date of service billed, the correct beneficiary and the specific service billed
  • Ensure that the documentation is complete with proper authentication and the signature is legible 

For more information, refer to Code of Federal Regulations, 42 CFR, Sections 410.32 and 424.5

5D920/5H920 — The Recommended Protocol Was Not Ordered and/or Followed
Reason for Denial

Medicare cannot pay for this service because one or more requirements for coverage were not met.

How to Avoid This Denial
Documentation that may be helpful to avoid future denials for this reason may include, but are not limited to, the following:

  • Clear physician’s order with indication of need, dose, frequency and route 
  • Date and time of associated chemotherapy, as applicable
  • Relevant medical history documented prior to the DOS and signed by the physician or appropriate nonphysician provider to include:
    • Clear indication of the diagnosis
    • Clinical signs and symptoms
    • Prior treatment and response as applicable
    • Stage of treatment as applicable 
  • Clear and complete documentation of administration signed by the person providing the service 
  • Ensure the service was provided per the coverage guidelines for the service
  • Documentation of administration

More Information

5D151/5H151 — Units Billed More Than Ordered
Reason for Denial 

The medical record provided for the outpatient service did not support the number of units billed on the claim. Per the documentation more units were billed than provided.

How to Avoid This Denial
Under the Outpatient Prospective Payment System (OPPS), when HCPC code reporting is required the number of times the service or procedure was performed, or the amount of the service used must also be accurately reported in the service units. 

  • For time-based general outpatient services, make sure the start and end time, or total length of the service is documented clearly in the record
  • For other general outpatient services, make sure the amount of the service is documented clearly in the record 
  • When reporting drugs or biologicals make sure the amount of the drug given is clearly documented and properly converted into units when submitted for payment 
  • For outpatient therapy services, make sure the timed treatment minutes for the timed services provided are documented clearly in the record

More Information

5D199/5H199 — Billing Error
Reason for Denial

The services billed were not covered because the documentation provided did not support the claim as billed by the provider.

How to Avoid This Denial
To avoid future denials for this reason:

  • Check all bills for accuracy prior to submitting to Medicare.
  • Ensure that the documentation submitted, in response to the ADR, corresponds with the date that the service was rendered, and the dates of service billed

More Information

5D162/5H162 — No Valid Plan of Care
Reason for Denial

For outpatient therapy services to be covered by the Medicare program they must be furnished under a written plan of care and the plan of care must be established before rendering treatment. The plan can be established by the physician or nonphysician practitioner (NPP), the treating physical therapist, occupational therapist, or speech-language pathologist. The NPP can be a physician assistant, nurse practitioner, or clinical nurse specialist. (Only a physician can establish a plan of care in a comprehensive outpatient rehabilitation facility.)

How to Avoid This Denial
Documentation and tips that may be helpful to avoid future denials for this reason may include, but are not limited to, the following: 

  • At a minimum, the plan of care must include:
    • A diagnosis or disabling conditions the services are intended to help with
    • Individualized goals, specific to the beneficiaries disabling condition
    • The type, amount, duration and frequency of the specific therapy service
    • Date that plan of care was developed
    • Signature of person who developed the plan of care (POC)
  • The plan of care must be kept up to date and accurately reflect the course of treatment being provided to the beneficiary. Changes and updates to the POC must be signed, same as the original development of the POC. The physician, NPP or treating therapist can make and sign these changes. 

More Information

  • 42 (CFR) Code of Federal Regulations — Sections 410.61 and 424.24
  • CMS Internet-Only Manual (IOM), Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220 (PDF, 1.55 MB)
  • Palmetto GBA Local Coverage Determinations which are available at LCDs, NCDs, Coverage Articles:
    • Outpatient physical therapy
    • Outpatient occupational therapy
    • Outpatient speech language pathology

The Next Steps
The service-specific targeted medical review edits for Outpatient Rehabilitation Services, CPT code 97140 — Manual Therapy — in Alabama, Georgia and Tennessee will be continued based on moderate charge denial rates and medium to high impact severity errors. If significant billing aberrancies are identified, provider-specific review may be initiated.

If you are dissatisfied with a claim determination you have the right to request an appeal. Palmetto GBA encourages you to review the documentation originally submitted, and if you believe you have additional supporting documentation you may include this information with your appeal. For more information related to the appeals process please refer to the Redetermination Appeal form (PDF, 236 KB). Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 877–567–7271.