Targeted probe and educate (TPE) round results: Rehabilitation services outpatient

Top denial / partial denial reasons and high-level results are listed below from each round of rehabilitation services outpatient TPE reviews that have been conducted thus far by Medical Review. 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:

• Medical necessity - The documentation submitted does not support medical necessity as listed in coverage requirements.
• Insufficient documentation - Insufficient documentation was provided to support the services as billed to Medicare. 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 submitted did not support the number of therapy minutes / units billed.
  • Documentation submitted was insufficient to support the plan of care.
  • Documentation submitted lacked a signed certification / recertification.
  • Documentation submitted did not support a valid plan of care.
  • Documentation submitted did not support the service was provided by PTA but was incorrectly billed.
  • Documentation submitted lacked evidence that the service was performed by the required expertise of the licensed therapist.
  • Documentation submitted lacked a valid signed plan of care.
  • Documentation submitted lacked an initial evaluation.
  • Documentation submitted did not support the reason for delayed / lacked (re)certification.
  • Documentation submitted lacked all required elements for the service billed.
  • Documentation submitted did not support the plan of care was established and signed by a qualified clinician/practitioner.
  • Documentation submitted did not support the appropriate supervision by a qualified clinician/professional.
  • Non-response to documentation requested.

Round results

CPT 97110

CPT 97112

CPT 97116

CPT 97140

CPT 97530