Part A service-specific review -- (CPT 97530 therapeutic activities)

On August 17, 2020, medical review activity resumed, as directed by CMS, with implementation of post-payment service-specific medical record review.

First Coast is tasked with preventing inappropriate Medicare payments. One of the ways this is conducted is through medical review of claims. This helps to ensure that Medicare pays for services that are covered, coded correctly, and medically reasonable and necessary. 

High level results and top denial / partial denial reasons are listed below for the post-payment service specific reviews for rehabilitation code for therapeutic activities CPT code 97530 that have been conducted by First Coast. If you have questions about your individual results, please contact the nurse reviewer assigned to your review for additional information.

Rehabilitation code 97530 therapeutic activities (January, February, March, April, May, June, July, and August 2021) 

Top full / partial denial reasons:

The most common reasons for denial or partial denials are the following:

• Medical necessity – Documentation submitted did not support the medical necessity of services billed.
• Insufficient documentation – Documentation submitted did not contain initial evaluations for start of treatment, 10th visit progress notes, and or updated plans of treatment to help support medical necessity of services billed.
• Documentation does not meet Local Coverage Determinations requirements – (i.e., certification / recertifications not completed or signed by physician.