Jurisdiction K Part A Targeted Probe and Educate: Medical Review Topics

Topic	CPT Code(s)	Common Denials	Resources
Debridement, subcutaneous tissue (includes epidermis and dermis, if performed)	11042, 11045	55B30 – The services billed were not documented in the records. 55B31 – The documentation submitted was incomplete/insufficient.	Local Coverage Determination (LCD): Debridement Services (L33614)
Individual Psychiatric Services	90832, 90834	55B00 – The claim was denied after review because the plan of treatment was missing or evidence of physician supervision/evaluation was not documented. 55B31 – The documentation submitted was incomplete/insufficient. Documentation lacks the required elements of the individualized treatment plan. Incident-to requirements were not met when services were provided by a non-physician practitioner.	Local Coverage Determination (LCD): Psychiatry and Psychology Services (L33632) CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 C Social Security Act 1815(a), 1833(e), and 1862(a)(1)(A) 42 CFR 424.5(A)(6)
Group Psychiatric Services	90853	55B00 – The claim was denied after review because the plan of treatment was missing or evidence of physician supervision/evaluation was not documented. 55B31 – The documentation submitted was incomplete/insufficient. Documentation lacks the individualized treatment plan/ required elements of the plan.	Local Coverage Determination (LCD): Psychiatry and Psychology Services (L33632) CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 C Social Security Act 1815(a), 1833(e), and 1862(a)(1)(A) 42 CFR 424.5(A)(6)
Cardiac Rehabilitation	93797, 93798	55B00 – The documentation submitted did not include a treatment plan. 55B12 – The submitted documentation does not support medical necessity as listed in coverage requirements. 55B31 – The documentation submitted was incomplete/insufficient. Documentation lacks individualized treatment plan. The treatment plan must be established, reviewed and signed by a physician every 30 days.	CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 232. CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 C and 3.3.2.4 Social Security Act 1815(a), 1833(e), and 1862(a)(1)(A) 42 CFR 424.5(A)(6)
Physical Therapy Re-Evaluation	97164	55B31 – The documentation submitted was incomplete/insufficient. 55T02 – The documentation submitted did not support the approval/certification of the plan of care for the therapy service(s). 55T11 – The documentation submitted did not support a significant change in condition or unresponsiveness to therapy interventions to support need for clinical re-evaluation.	Local Coverage Determination (LCD): Outpatient Physical and Occupational Therapy Services (L33631) CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 220.1.3 A and 220.3.C CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 C Social Security Act 1815(a), 1833(e), and 1862(a)(1)(A) 42 CFR Section 409.44 (c)(2)(F) and 424.24
Wound Debridement	97597, 97598	55B30 – The services billed were not documented in the records 55B31 – The documentation submitted was incomplete/insufficient.	Local Coverage Determination (LCD): Debridement Services (L33614) CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 100 CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Sections 20.5.2 and 20.5.3 CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 5, Sections 20 and 100.7, Chapter 12, Sections 30.6, 30.6.6 B, and 40.3 42 CFR 410.26, Section 410.27
Hyperbaric Oxygen (HBO)	G0277	55B31 – The documentation submitted was incomplete/insufficient. The submitted medical records lack documentation to support the diagnosis identified. 55C28 – The submitted documentation did not support that the patient has failed an adequate course of standard wound therapy for diabetic wound management.	National Coverage Determination 20.29 CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 C; Social Security Act 1815(a), 1833(e), and 1862(a)(1)(A) 42 CFR 424.5(A)(6)
Drugs and Biologicals - IVIG (Privigen)	J1459	55B12 – The submitted documentation does not support medical necessity as listed in coverage requirements. 55B31 – The documentation submitted was incomplete/insufficient. The submitted medical records lack documentation to support the diagnosis identified.	Local Coverage Determination (LCD): Drugs and Biologicals, Coverage of, for Label and Off-Label Uses (L33394) Local Coverage Determination (LCD): Off-Label Use of Intravenous Immune Globulin (IVIG) (L39314) CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.2 and 50.6 CMS IOM Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 250.3 CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Sections 3.2.3.8 C, 3.4.1.3, 3.6.2.1, 3.6.2.2 Social Security Act 1815(a), 1833(e), and 1862(a)(1)(A) 42 CFR 424.5(A)(6)
Drugs and Biologicals - Immune globulin (gammagard liquid), non-lyophilized, 500 mg	J1569	55B31 – The documentation submitted was incomplete/insufficient. The submitted medical records lack documentation to support the diagnosis identified.	Local Coverage Determination (LCD): Drugs and Biologicals, Coverage of, for Label and Off-Label Uses (L33394) Local Coverage Determination (LCD): Off-Label Use of Intravenous Immune Globulin (IVIG) (L39314) CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.2 and 50.6 CMS IOM Publication 100-03, Medicare Program Integrity Manual, Chapter 1, Section 250.3
Drugs and Biologicals – Infliximab (Remicade)	J1745	55B31 – The documentation submitted was incomplete/insufficient.	Local Coverage Determination (LCD): Drugs and Biologicals, Coverage of, for Label and Off-Label Uses (L33394) FDA label for Remicade CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 50 and 50.4.5 CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 17, Sections 10 and 40
Drugs and Biologicals – Omalizumab (Xolair)	J2357	55B12 – The submitted documentation does not support medical necessity as listed in coverage requirements. 55B31 – The documentation submitted was incomplete/insufficient. The submitted medical records lack documentation to support the diagnosis identified.	CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Sections 3.2.3.8 C and 3.6.2.2 Social Security Act 1815(a), 1833(e), and 1862(a)(1)(A) 42 CFR 424.5(A)(6)
Skilled Nursing Facility – PDPM Medical Necessity	N/A	55S00 – The documentation needed to make payment was missing/incomplete. 55S03 – The information provided does not support the need for skilled nursing facility care. 55S04 – The information provided does not support documentation on the MDS. 55S08 – The beneficiary did not have a qualifying hospital stay prior to admission to the SNF.	Skilled Nursing Facility PPS \| CMS MDS 3.0 RAI Manual v1.17.1_October 2019 (cms.gov) Skilled Nursing Facility Center \| CMS Patient Driven Payment Model Fact Sheet \| CMS
Inpatient Rehabilitation Services	N/A	55F36 – The documentation does not support that upon admission to the IRF the patient generally required the intensive rehabilitation therapy services that are uniquely provided in IRFs. 55F40 – The documentation does not support the patient was sufficiently stable at discharge from the acute care setting to the point the patient would be able to fully participate in the intense rehabilitative treatment provided in the IRF setting.	CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 110.2-110.2.2 CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 C Social Security Act 1815(a), 1833(e), and 1862(a)(1)(A) 42 CFR 412.622(a)(3) and (a)(3)(i)
Outpatient Physical Therapy, Occupational Therapy, and/or Speech Language Pathology	All therapy codes when billed with KX modifier	55B31 – The documentation submitted was incomplete/insufficient. 55T16 – The documentation submitted lacked evidence to support the ongoing skills of a qualified therapist were required to complete the treatment. 55T17 – The documentation submitted did not support the initiation of therapy treatment services were medically necessary.	Local Coverage Determination (LCD): Outpatient Physical and Occupational Therapy Services (L33631) CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.2 CMS IOM Publication 100- 08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 C Social Security Act 1815(a), 1833(e), and 1862(a)(1)(A) 42 CFR Section 409.44 (c)

*Not an all-inclusive list of resources

If a non-response to an ADR occurs, the claim may deny with the reason code 56900. A 56900 denial will negatively impact a provider's error rate and may result in additional rounds of TPE review. By implementing TPE best practices and responding to ADRs, this is an easily preventable denial.

Additional References

Posted 8/28/2023