Pre-Payment Review Results for Neuromuscular Reeducation for October to December 2024

Published 03/19/2025

The Centers for Medicare & Medicaid Services (CMS) Implemented the Targeted Probe & Educate (TPE) Process for Neuromuscular Reeducation for October to December 2024

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

Cumulative Results

Table 1. Cumulative Results.
 Number of Providers with Edit Effectiveness Providers Compliant Completed/Removed After Probe  Providers Non-Compliant Progressing to Subsequent Probe Providers Non-Compliant/Removed for Other Reason
1 1 0 0
Table 2. Cumulative Results.
Number of Claims with Edit Effectiveness  Number of Claims Denied  Overall Claim Denial Rate  Total Dollars Reviewed Total Dollars Denied Overall Charge Denial Rate
40 6 15% $10,362.84 $1,076.73 10%

Probe One Findings

Table 3. Probe One Findings.
State Number of Providers with Edit Effectiveness Providers Compliant Completed/Removed After Probe  Providers Non-Compliant Progressing to Subsequent Probe Providers Non-Compliant/Removed for Other Reason
Ala. 0 0 0 0
Ga. 0 0 0 0
Tenn. 1 1 0 0
Table 4. Probe One Findings.
State Number of Claims with Edit Effectiveness Number of Claims Denied Overall Claim Denial Rate Total Dollars Reviewed Total Dollars Denied Overall Charge Denial Rate
Ala. 0 0 0% $0.00 $0.00 0%
Ga. 0 0 0% $0.00 $0.00 0%
Tenn. 40 6 15% $10,362.84 $1,076.73 10%

Risk Category

The categories for Neuromuscular Reeducation are defined as:

Table 5. Risk Category.
Risk Category Error Rate
Minor 0–20%
Major 21–100%
Figure 1. Risk Category for Neuromuscular Reeducation/CPT® 97112.

Pie chart showing 100% minor.

Top Denial Reasons

Table 6. Top Denial Reasons.
Percent of Total Denials Denial Code Denial Description Number of Occurrences
10% 5D165, 5H165 No Physician Certification/Recertification 1

Denial Reasons and Recommendations

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

References

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. 


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