Review Results for Service Specific Post-Payment Review of Therapeutic Procedure, 1 or More Areas, Each 15 Minutes; Aquatic Therapy with Therapeutic Exercise - CPT 97113

Background

In an effort to reduce the Part B CERT error rate, the MR Department conducted a service specific post payment review of CPT code 97113 (Aquatic therapy with therapeutic exercises, 1 or more areas, each 15 minutes).The primary focus of these audits was to determine whether the medical necessity of the services billed was at the correct code per Medicare guidelines.

NGS randomly selected 400 claims billed for CPT 97113 for post payment review in Jurisdiction 6 for Part B providers in the states of Illinois, Minnesota and Wisconsin.

CPT code 97113 (Aquatic therapy with therapeutic exercises, 1 or more areas, each 15 minutes).

Results

Decision	Number of Claims
Allow	157
Deny	174
Partially Deny	1
Non-Response Denial	67

189 claims from Illinois with 74 allowed and 115 denied for a claims error rate of 60.85%
118 claim from Minnesota with 40 allowed and 78 denied for a claims error rate of 66.10%
93 claims from Wisconsin with 43 allowed and 50 denied for a claims error rate of 53.76%

Key Reasons Services Were Denied

Documentation did not support medically necessity due to one or more of the following: records did not support the skills of a therapist were required, records did not include physician certification, initial evaluation, the plan of care, including the prior level of function, the frequency and duration of services or goals with time line for completion.
Documentation was insufficient or incomplete
Failure to respond to the request for documentation

Recommendations

Send the requested records within the requested time frame to avoid a denial for no documentation
Familiarize yourself with available Physical Therapy use guidelines and other CMS publications listed below
Share this information with your coding personnel to ensure they are properly billing before sending the claim to Medicare.
If you feel your application of this code is correct, ensure your documentation supports your usage.

Related Content

Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled
- Section 1815 – Payment to Providers of Services Social Security Act Section 1815
- Section 1833(e)- Payment of Benefits Social Security Act Section 1833
- Sections 1861(g), 1861(p), 1861(s)(2) and 1862(a)(14) of Title XVIII of the Social Security Act define the services of non-physician practitioners. Social Security Act Section 1861
- Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer and Section 1862(a)(20) Social Security Act Section 1862
Code of Federal Regulations, Title 42 Public Health
- 42 CFR, Sections 410.59 through 410.61, 410.74, 410.75, 410.76, 419.22, 424.24, 424.27, 424.4, 482.56, 484, 485.705 and 486 Code of Federal Regulations - Title 42
CMS Publications: Internet Only Manuals
- CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15: Sections 220 through 230, Coverage and documentation requirements for physical and occupational therapy services.
- CMS IOM Publication 100-03, Medicare National Coverage Decisions (NCD) Manual, (multiple sections): provides coverage information on several specific types of therapy services.
- CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 5, Section 10.2, financial limitation for therapy services (therapy cap) and Section 20-100 HCPCS coding and therapy billing requirements.
- Local Coverage Article: Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)
- Local Coverage Determination: Outpatient Physical and Occupational Therapy Services (L33631)