Medical Review

Service Specific Post Payment Review Summary Results of Physical Therapy Reevaluation (5FUFP)

On 11/25/2020 NGS Part A MR Department initiated a service specific post-payment review of randomly selected claims billed for the following services mentioned in J6 for Part A providers in the states of Wisconsin, Illinois, and
 Minnesota.

  • Edit Reason Code: 5FUFP
  • Bill Type: 13X
  • CPT/HCPCS/Modifiers: 97164, Reevaluation of physical therapy established plan of care

The results of this review provide a summary of claims with dates of service 01/01/19 through 02/28/20. 

Note: Results are for post-payment medical record determinations only and do not include appeal results for overturns and decision reversals.

Findings

Error Rate Calculations

Claims Rate
Claims Reviewed 268
# Claims Denied 180
CER 49.32%
PER 48.21%

Top Denials

  • Reason Code 56900: No response from medical record request.
    • 97 claims denied.
    • Reason code 56900 will occur when providers do not respond to an ADR. This reason code can and should be prevented. When providers receive an ADR, respond according to the date listed in the ADR. Providers should start gathering the documentation being requested immediately. This will ensure that there is adequate time to gather all of the supporting documentation that is being requested so that the timeframe for submitting the information can be met. Depending on what is being requested, providers may have to go outside of their facilities to get the supporting documentation and this may require time to be received from that entity.
  • Reason Code 55B17: Claim/services was denied the physician certification was incomplete, invalid or absent.    
    • 47 claims denied.
  • Reason Code 55B12: Claim/service denied after review and it was determined the medical record did not support medical necessity
    • 17 claims denied.
  • Reason Code 55B31: Claim/service denied indicating that the documentation needed to make payment was missing/incomplete.
    • 13 claims denied.
    • Insufficient or no medical records were received to support the service was rendered.​​​​​​

Related Content

Posted 9/1/2021

Helpful Resources

Targeted Probe and Educate Manual

Ways to submit Medical Records: Paper, Fax, CD, esMD

NGSConnex
NGSConnex
NGSConnex User Guide

USPS
National Government Services, Inc.
P.O. Box 7108
Indianapolis, IN 46207-7108

UPS/FedEx
National Government Services, Inc.
6345 Castleway Court
Indianapolis, IN 46250
ATTN: Mail & Distribution
*Add/insert the operational unit record to be scanned

Direct Fax
315-442-4390

Helpful Resources

Targeted Probe and Educate Manual

Ways to submit Medical Records: Paper, Fax, CD, esMD

NGSConnex
NGSConnex
NGSConnex User Guide

USPS
National Government Services, Inc.
P.O. Box 7108
Indianapolis, IN 46207-7108

UPS/FedEx
National Government Services, Inc.
6345 Castleway Court
Indianapolis, IN 46250
ATTN: Mail & Distribution
*Add/insert the operational unit record to be scanned

Direct Fax
315-442-4154

Helpful Resources

Targeted Probe and Educate Manual

Ways to submit Medical Records: Paper, Fax, CD, esMD

NGSConnex
NGSConnex
NGSConnex User Guide

USPS
National Government Services, Inc.
P.O. Box 6474
Indianapolis, IN 46206-6474

UPS/FedEx
National Government Services, Inc.
6345 Castleway Court
Indianapolis, IN 46250
ATTN: Mail & Distribution
*Add/insert the operational unit record to be scanned

Direct Fax
315-442-4154

Helpful Resources

Targeted Probe and Educate Manual

Ways to submit Medical Records: Paper, Fax, CD, esMD

NGSConnex
NGSConnex
NGSConnex User Guide

USPS
National Government Services, Inc.
P.O. Box 7108
Indianapolis, IN 46207-7108

UPS/FedEx
National Government Services, Inc.
6345 Castleway Court
Indianapolis, IN 46250
ATTN: Mail & Distribution
*Add/insert the operational unit record to be scanned

Direct Fax
315-442-4231

Helpful Resources

Targeted Probe and Educate Manual

Ways to submit Medical Records: Paper, Fax, CD, esMD

NGSConnex
NGSConnex
NGSConnex User Guide

USPS
National Government Services, Inc.
P.O. Box 6475
Indianapolis, IN 46206-6475

UPS/FedEx
National Government Services, Inc.
6345 Castleway Court
Indianapolis, IN 46250
ATTN: Mail & Distribution
*Add/insert the operational unit record to be scanned

Direct Fax
317-595-4364

Helpful Resources

Targeted Probe and Educate Manual

Ways to submit Medical Records: Paper, Fax, CD, esMD

NGSConnex
NGSConnex
NGSConnex User Guide

USPS
National Government Services, Inc.
P.O. Box 6474
Indianapolis, IN 46206-6474

UPS/FedEx
National Government Services, Inc.
6345 Castleway Court
Indianapolis, IN 46250
ATTN: Mail & Distribution
*Add/insert the operational unit record to be scanned

Direct Fax
315-442-4154

Helpful Resources

Targeted Probe and Educate Manual

Ways to submit Medical Records: Paper, Fax, CD, esMD

NGSConnex
NGSConnex
NGSConnex User Guide

USPS
National Government Services, Inc.
P.O. Box 7108
Indianapolis, IN 46207-7108

UPS/FedEx
National Government Services, Inc.
6345 Castleway Court
Indianapolis, IN 46250
ATTN: Mail & Distribution
*Add/insert the operational unit record to be scanned

Direct Fax
315-442-4390

Helpful Resources

Targeted Probe and Educate Manual

Ways to submit Medical Records: Paper, Fax, CD, esMD

NGSConnex
NGSConnex
NGSConnex User Guide

USPS
National Government Services, Inc.
P.O. Box 7108
Indianapolis, IN 46207-7108

UPS/FedEx
National Government Services, Inc.
6345 Castleway Court
Indianapolis, IN 46250
ATTN: Mail & Distribution
*Add/insert the operational unit record to be scanned

Direct Fax
315-442-4390