Pre-Payment Review Results for Manual Therapy for October to December 2024

The Centers for Medicare & Medicaid Services (CMS) implemented the Targeted Probe & Educate (TPE) process for Current Procedural Terminology (CPT®) code 97140 for Manual Therapy

The reviews with edit effectiveness are presented here for Alabama, Georgia and Tennessee. 

Cumulative Results

Probe One Findings

Probe Two Findings

Probe Three Findings

Risk Category

The categories for Manual Therapy are defined as:

Top Denial Reasons

Denial Reasons and 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
  • Legible documentation
• Submit all documentation to support ongoing skills of a qualified therapist were required to complete the treatment and that the initiation of therapy treatment services were medically necessary
• ABN is valid, complete, and submitted in the record if applicable
• 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
• Submit treatment note documentation that contains date of treatment, description of modality/procedure to support accurate billing, total treatment minutes/ total timed code treatment minutes and signature of qualified professional
• Documentation to include the therapy discharge note and summary
• All documentation submitted is legible

Resources

• Code of Federal Regulations, 42 CFR — Section 411.15
• CMS Internet Only Manual (IOM), Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4 (PDF)
   

5D165/5H165 — No Physician Certification/Recertification

Reason for Denial
For outpatient therapy services to be covered by the Medicare program, the plan of care must be certified by the physician or nonphysician practitioner (NPP). Certification means that the physician or NPP has signed and dated the plan of care or some other document that indicates approval of the plan of care. No valid physician certification or recertification was submitted.

How to Avoid This Denial

• The plan of care must be complete and valid for the certification to be valid
• The physician/NPP signature on the certification must be legible
• The documentation must support the plan of treatment was established and signed by the physician prior to the initiation of therapy services
• The initial certification should be signed/dated within 30 days of the first day of treatment (including the evaluation)
• The recertification must occur at least every 90 calendar days
• The physician/NPP signature on the certification must be legible for the certification to be valid
• If certification is provided on a separate document other than the actual plan of care, there must be documentation to support the certifying physician/NPP had access to the plan of care for review. This can be a statement on the document for the physician/NPP, a fax log showing where the plan of care was forwarded to the physician/NPP, or a note in the therapy record indicating the plan of care was forwarded to the physician/NPP
• The documentation must show evidence of delayed certification or attempts to obtain certification from the physician/NPP or reason for delayed/lapsed (re)certification

Resources

• 42 (CFR) Code of Federal Regulations, Sections 409.17, 410.61, 410.61(B), 424.11(d)(3), and 424.24
• CMS IOM, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 220, 220(A), 220.1.2A, 220.1.3 A, 220.1.3 B-D, and 220.1.3 C-D (PDF)
• Palmetto GBA Local Coverage Determinations
  • Outpatient physical therapy
  • Outpatient occupational therapy
  • Outpatient speech-language pathology 
• CMS IOM, Pub. 100-8, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4, Signature Requirements (PDF)
   

5D169/5H169 — Insufficient Documentation

Reason for Denial
This claim was partially or fully denied because the documentation submitted is insufficient for the services billed. 

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 

Resources

• Social Security Act 1815
• 42 CFR — 424.5(a)(6)
• CMS IOM, Pub. 100-8, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 C (PDF)
   

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:

For Drugs and Biologicals:

• Clear physician’s order with indication of need, dose, frequency, administration time 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, but not limited to:
  • Clear indication of the diagnosis and need for the related service(s)
  • Clinical signs and symptoms
  • Prior treatment and response as applicable
  • Stage of treatment as applicable
  • Documentation of administration and signed by the person providing the service
• Ensure the service was provided per the coverage guidelines for the service

For Outpatient Therapy: 

• Clear physician’s order with indication of specific skilled service, frequency and duration
• Relevant medical history documented prior to the DOS and signed by the physician or appropriate nonphysician provider to include, but not limited to:
  • Clear indication of the diagnosis and need for the related therapy services 
  • Documentation related to the therapy services to include beneficiary's functional level, treatment plan, short- and long-term goals, beneficiary's response to therapy services, treatment and progress notes.  
  • Prior treatment and response as applicable
• Ensure the service was provided per the coverage guidelines for the service

For IMRT:

• Clear physician/radiation oncologist orders for radiation treatment course, including specific anatomical target volumes, treatment technique, current dosage, type of radiation measuring and monitoring devices to be used and treatment fields
• Relevant medical history documented prior to the DOS and signed by the physician/radiation oncologist or appropriate nonphysician provider to include:
  • Clear indication of the diagnosis being treated and medical necessity of the services
  • Supporting reports such as dosimetry, physicist, simulation, oncology and radiology
  • Documentation of design and construction of Multi-Leaf Collimator
  • Detailed itemized bill and supporting documentation of all billed services 
  • Documentation of treatment plan, including goals, treatment notes, specific dose constraints for the target and administration
• Ensure the service was provided per the coverage guidelines for the service

Resources

• Drugs and Biologicals: CMS IOM, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50 (PDF)
• Drugs and Biologicals: CMS IOM, Pub. 100-04, Medicare Claims Processing Manual, Chapter 17 (PDF)
• Outpatient Therapy: CMS IOM, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 220, 230 (PDF)
• IMRT: CMS IOM, Pub. 100-04, Medicare Claims Processing Manual, Chapter 4, Section 200.3.1 (PDF)
   

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

• 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

Resources

• CMS IOM, Pub. 100-04, Medicare Claims Processing Manual, Chapter 4, 200.3.1 and 200.3.2 (PDF)
• CMS IOM, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23 (PDF)
• CMS IOM, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.4 (PDF)
   

Education
Palmetto GBA offers providers selected for TPE an individualized education session to discuss each claim denial. This is an opportunity to learn how to identify and correct claim errors. A variety of education methods are offered such as webinar sessions, web-based presentations or teleconferences. Other education methods may also be available. Providers do not have to be selected for TPE to request education. If education is desired, please complete the Education Request Form (PDF).               

Next Steps
Providers found to be non-compliant (major risk category/denial rate of 21–100 percent) at the completion of TPE Probe 1 will advance to Probe 2, and providers found to be non-compliant (major risk category/denial rate of 21–100 percent) at the completion of TPE Probe 2 will advance to Probe 3 of TPE after at least 45 days from completing the 1:1 post-probe education call date.