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March 22, 2021

Notification of Service Specific Post Payment Review for Physical Therapy/Occupational Therapy: CPT Codes 97110, 97112, 97140, 97530

Beginning August 17, 2020, CMS directed the MACs to resume fee-for-service medical review activities beginning with post payment reviews of items/services provided before March 1, 2020. Items and services are selected based upon high error rates and/or potential overutilization identified through data analysis.

The goal of CGS's Medical Review (MR) program is to reduce errors through claims reviews and education on Medicare's coverage, coding, payment and billing policies. To achieve this goal, we conduct data analysis to identify provider billing services of CPT/HCPCS codes that pose the greatest risk to the Medicare program.

The reviews involve providers billing CPT codes 97110 (Therapeutic exercises), 97112 (Neuromuscular reeducation), 97140 (Manual therapy techniques), and 97530 (Therapeutic activities.) Documentation will be reviewed for compliance with Medicare rules and regulations such as: medical necessity; required components and signatures; deliverance of the service; as well as correct coding and billing per medical necessity.

Additional Documentation Request (ADR) letters will be sent. Please submit requested documentation within 45 days of receipt of the ADR letter. Please include a copy of your ADR letter and claim cover sheet with each claim documentation submission. Failure to respond by the 45th day will result in denial for non-response and recoupment of dollars paid in error.

Documentation Necessary to Process the Claim

We expect all documentation submitted with each ADR letter to be legible and include a copy of the following from each patient's medical record:

  1. Beneficiary's name
  2. Date of service (DOS)
  3. Initial Order for therapy from ordering provider if DOS reviewed is first visit

Documentation required:

  1. Initial Certification signed by ordering provider within 30 days of DOS to include:
    • Diagnosis
    • Long term measurable goals
    • Type, amount, duration and frequency of services
    • Necessity of skilled therapy of a skilled therapist through objective findings and subjective patient self-reporting
  2. Subsequent Certification/Recertification signed by ordering provider within 30 days of DOS
    • Diagnosis
    • Objective measurable functional limitations including objective assessment scores/summaries
    • Functional assessment
    • Clinical judgment
  3. Delayed Certification signed greater than 30 days after DOS
    • Should include any evidence by the billing provider to justify delay
    • Should be specific to the patient and situation (no cloned or generalized statements)
  4. Progress notes every 10th visit
    • Establish medical necessity of continued treatment
    • Assessment of improvement, extent of progress (or lack thereof) toward each goal
    • Necessity of skilled therapy of a skilled therapist through objective findings and subjective patient self-reporting
    • Plan for continuing treatment
    • Objective evidence consisting of standardized patient assessment instruments, outcome measurements tools or measurable assessments of functional outcome
    • Changes to long or short-term goals
  5. Treatment Note:
    • Date of treatment
    • Identification of each specific intervention/modality provided
    • Both timed and untimed codes
    • Documented in language that can be compared with the codes billed
  6. Copy of ABN's as applicable
  7. Appropriate signatures - The treatment note should include the signature and professional identification of who furnished (or supervised) the services and a list of each person who contributed to that treatment
    • Signature and credentials of person performing the service
    • Amendments/corrections/delayed entries are properly identified
    • Amendments/corrections/delayed entries are initialed and dated by Author within 30 days of the billed service.

For more information regarding signature requirements, please visit our website.

Guidelines regarding signature requirements are located in the CMS Internet-only Manual (IOM) Publication (Pub.) 100-08, Chapter 3, Section 3.3.2.4External PDF, "Signature Requirements." Information is also available in CMS MLN Matters article MM6698External PDF, "Signature Guidelines for Medical Review Purposes."

Notification of Results

Providers will be notified via results letter for denied claims with an estimated overpayment.  You will receive a letter from Overpayment Recovery with the final overpayment amount. If you disagree with the decision, you may request a redetermination within 120 days of the date of your demand letter.

References:

Local Coverage Determination (LCD): Outpatient Physical and Occupational Therapy Services (L34049)External Website

CMS Internet-only Manual (IOM) Publication (Pub.) 100-02, Chapter 15, Section 220External PDF

MLN905365 Outpatient Rehabilitation Therapy Services: Complying with Documentation RequirementsExternal PDF

CGS Outpatient Physical and Occupational Therapy Services Fact SheetPDF

CGS MR Activities

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