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

Published 02/19/2025

Pre-Payment Review Results for Neuromuscular Reeducation 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 97112 for Neuromuscular Reeducation. The reviews with edit effectiveness are presented here for North Carolina, South Carolina, Virginia and West Virginia.

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
4 4 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
100 2 2% $32,703.55 $111.43 0.34%

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
N.C. 1 1 0 0
S.C. 1 1 0 0
Va. 1 1 0 0
W.Va. 0 0 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
N.C. 20 1 5% $5,821.37 $41.04 1%
S.C. 40 1 3% $12,500.08 $70.39 1%
Va. 20 0 0% $5,550.85 $0 0%
W.Va. 0 0 0% $0 $0 0%

Probe Two Findings

Table 5. Probe Two 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
N.C. 0 0 0 0
S.C. 0 0 0 0
Va. 1 1 0 0
W.Va. 0 0 0 0
Table 6. Probe Two 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
N.C. 0 0 0% $0 $0 0%
S.C. 0 0 0% $0 $0 0%
Va. 20 0 0% $8,831.25 $0 0%
W.Va 0 0 0% $0 $0 0%

Risk Category

The risk categories for CPT® code 97112 for Neuromuscular Reeducation are defined as:

Table 7. Risk Category.
Risk Category Error Rate
Minor 0–20%
Major 21–100%

Pie chart showing 100 minor findings

Top Denial Reasons

Table 8. Top Denial Reasons.
Percent of Total Denials Denial Code Denial Description Number of Occurrences
33% 5D164, 5H164 No Documentation of Medical Necessity 1
33% 5D165, 5H165 No Physician Certification/Recertification 1
33% 5D199, 5H199 Billing Error 1

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 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

Resources

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 POC, 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.
  • 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

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

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.

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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