Pre-Payment Review Results for Therapeutic Exercise for October to December 2024

Published 03/24/2025

Pre-Payment Review Results for Therapeutic Exercise for Targeted Probe and Educate (TPE) for October to December 2024

The Centers for Medicare & Medicaid Services (CMS) implemented the TPE process for Current Procedural Terminology (CPT®) code 97110 for Therapeutic Exercise 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
31 24 7 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
1,237 168 14% $339,751.68 $28,600.12 8%

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. 18 12 6 0
Ga. 4 4 0 0
Tenn. 9 8 1 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. 720 136 19% $197,044.16 $23,857.61 12%
Ga. 160 13 8% $39,477.70 $1,516.23 4%
Tenn. 357 19 5% $103,229.82 $3,226.28 3%

Risk Category

The categories for Current Procedural Terminology (CPT®) code 97110 for Therapeutic Exercise are defined as:

Table 5. Risk Category.
Risk Category Error Rate
Minor 0–20%
Major 21–100%

Figure 1. Risk Category for Therapeutic Exercise/CPT® 97110.

Pie chart showing 77% minor and 23% major.

Top Denial Reasons

Table 6. Top Denial Reasons.
Percent of Total Denials Denial Code Denial Description Number of Occurrences
20% 5D165, 5H165 No Physician Certification/Recertification 14
19% 5D151, 5H151 Units Billed More Than Ordered 13
17% 5D169, 5H169 Insufficient Documentation 12
13% 56900 Requested Records Not Submitted Timely 9
10% 5D164, 5H164 No Documentation of Medical Necessity 7

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 (POC) must be certified by the physician or nonphysician practitioner (NPP). Certification means that the physician or NPP has signed and dated the POC or some other document that indicates approval of the POC. No valid physician certification or recertification was submitted. 

How to Avoid This Denial

  • The POC 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 POC 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.

References

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 HCPCS 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

References

5D169/5H169 — Insufficient Documentation 

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

References

56900 — Auto Deny — Requested Records Not Submitted Timely 

Reason for Denial
The services billed were not covered because the documentation was not received in response to the Additional Documentation Request (ADR) and therefore, we were unable to determine the medical necessity of the service billed. The provider has 45 days from the date the ADR was generated to respond with medical records. If less than 120 days after denial notification on the remittance advice, submit records to the contractor requesting records at the address listed on the original ADR to request reopening. Do not resubmit the claim.

How to Avoid This Denial

  • Be aware of the ADR date and the need to submit medical records within 45 days of the ADR date
  • Submit the medical records as soon as the ADR is received
  • Monitor the status of your claims in Direct Data Entry (DDE) and begin gathering the medical records as soon as the claim goes to the location of SB6001
  • Return the medical records to the address on the ADR. Be sure to include the appropriate mail code or station number. This ensures that your responses are promptly routed to the medical review department. Fax and electronic data submissions are also accepted as indicated on the ADR.
  • Gather all of the information needed for the claim and submit it all at one time 
  • Attach a copy of the ADR request to each individual claim
  • If responding to multiple ADRs, separate each response and attach a copy of the ADR to each individual set of medical records. Make sure each set of medical records is individually identifiable and bound securely to ensure that no documentation is detached or lost. Do not use paper clips. 
  • Do not mail packages C.O.D.; we cannot accept them

Resources

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 billed is documented in the record
    • 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

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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