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Targeted probe and educate (TPE) round results - Rehabilitation services CPT 97112
Last Modified: 8/2/2024
Location: FL, PR, USVI
Business: Part A, Part B
Rehabilitation services CPT 97112, 97140, 97110, 97116, 97124, 97530
Top denial/partial denial reasons and high-level results are listed below from each round of JN Rehabilitation Services TPE reviews that have been conducted thus far by First Coast. If you have questions about your individual results, please contact the nurse reviewer assigned to your review for additional information. Additional rounds of review will be utilized when the targeted topic demonstrates a continued need for review with newly identified providers.
Top denial/partial denial reasons:
The most common reasons for denial or partial denials are the following:
1. Medical necessity - The documentation submitted does not support medical necessity as listed in coverage requirements.
2. Insufficient documentation – Insufficient documentation was provided to support the services as billed to Medicare. First Coast Medical Review makes multiple attempts to correct these error types before completion of the review. Below are the following denial reasons for insufficient documentation that we were not able to resolve:
• Documentation to support number of therapy minutes/units billed.
• Documentation of therapy evaluation of care to support services billed.
• Documentation of signed initial certification/recertification.
• Documentation submitted was lacking evidence of a certified/re-certified plan of care by the ordering/treating provider. (No evidence of delayed certification or attempted to obtain delayed certification.
• Documentation submitted was missing diagnoses and/or long-term goals in plan of care.
• Documentation submitted lacked evidence of a progress note/report every 10 visit to meet requirements and/or signed by the PT.
• Documentation submitted lacked evidence that the service was performed required the expertise of the licensed therapist.
• Documentation submitted did not support a service on the billed date for the beneficiary.
• Documentation submitted did not support the units billed, or the therapeutic interventions.
• Documentation submitted did not support the time spent performing the rehabilitation service.
• Documentation did not support a valid plan of care as the documentation lacked measurable treatment goals, goal-oriented outcomes, or therapeutic Interventions.
• Non-response to documentation request.
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