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Novitas Posts TPE Results for PT and OT

Novitas Posts TPE Results for PT and OT

Round 1 of Novitas Solutions’ targeted probe and educate (TPE) review for outpatient physical and occupational therapy (CPT® codes 97010-97546) indicates there is room for improvement in getting claims paid.

TPE Results Are In

The Medicare Administrative Contractor’s (MAC) TPE round 1 results for CPT® 97530 Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes, for example, was:

  • In jurisdiction H, 78 percent minor errors, 11 percent moderate errors, and 11 percent major errors
  • In jurisdiction L, 67 percent minor errors, 15 percent moderate errors, and 18 percent major errors

Reasons for Denials

The most common reasons for denials found during the TPE were due to:

  • Medical necessity not shown in documentation
    • Must show certified/re-certified plan of care by the ordering/treating provider.
    • Include progress note/report every 10 visits.
    • Show that the service required a licensed therapist.
  • Insufficient documentation for:
    • No response to additional documentation requests.
    • Therapy assistant use requirements not met.
    • Documentation did not support the amount of time spent.
    • Incorrect date of service

Other billing errors and incorrect coding were also found.

Resources Available

Novitas provides a documentation checklist for therapy services for providers to use when responding to additional documentation requests (ADRs).

A MAC may conduct up to three rounds in the TPE process and refer a provider to CMS if denials remain high. The Centers for Medicare & Medicaid Services then determines what action to take.

Topics for review and providers are based on existing data analysis procedures outlined in CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 2.

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Renee Dustman, BS, AAPC MACRA Proficient, is managing editor - content & editorial at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 30 years' experience in journalistic reporting, print production, graphic design, and content management. Follow her on Twitter @dustman_aapc.

3 Responses to “Novitas Posts TPE Results for PT and OT”

  1. Mary R. Daulong says:

    Thank you for sharing.

    Could you please tell me what was the review period and when were these reviews conducted?

  2. Juliet L. Boltz says:

    This is what I did for Workmen’s Insurance Claim in my previous work as Rehab Massage therapist.
    Re Reasons for Denials, medical necessity not shown in documentation
    1. Must show certified/re-certified plan of care by the ordering/treating provider.
    From Neuro Department of Laurence & Memorial ( L & M ) Hospital, New London CT
    Doctors order with diagnosis code and pre-approved insurance claim for number of weeks
    of rehab. Used CMS 1500 claim form for insurance, patient’s info, Diagnosis code and CPT claim codes every
    15 minutes and pricing. I did the sessions in my office.
    2. Include progress note/report every 10 visits.
    Documented every visit, recorded before and after treatment as described by the patient and my overall
    summary. Enclosed copies of areas worked describing with pictures from my training from SRA ( Spinal Reflex
    Analysis) /Spinal Reflex Therapy.
    3. Show that the service required a Licensed Therapist.
    Letter head describing my specialties and place of work contact info. Addressed to Insurance
    Supervisor assigned for specific patient. Described the number of sessions from date to date of claim. I don’t
    have any denials. I clocked from submission to payment takes a whole month.

  3. Renee Dustman says:

    Mary: I don’t have that information but here’s the link to where I go my info: