Targeted Probe and Educate Topics

Jurisdiction 6 Part A Targeted Probe and Educate: Medical Review Topics

Topic CPT Code(s) Common Denials Resources
Nail Debridement 11719-11721 55B23– The service provided is not covered Medicare benefit.
  • Routine foot care
55B31 – The documentation submitted was incomplete/insufficient.
  • Insufficient documentation to support patient is under the active care of a doctor for the treatment and/or evaluation of the complicating disease process during the six (6) month period prior to the rendition of the routine-type service.
 Local Coverage Determination (L33636): Routine Foot Care and Debridement of Nails

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 411.15 and 424.5(A)(6)
Individual Psychotherapy 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 Psychotherapy 90853
55B41– The claim was denied after review and it was determined that the services billed were not provided by staff licensed or otherwise authorized (by the state) to render the services.

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)
Physician Services For Outpatient Cardiac Rehabilitation; With Continuous ECG Monitoring (Per Session) 93798
 		 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 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
Hyperbaric Oxygen (HBO) G0277 55B31 – The documentation submitted was incomplete/insufficient.
  • The submitted medical records lack documentation to support the diagnosis identified.
55C01– The documentation does not support a covered diagnosis.		 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)
Injection, Immune Globulin (Privigen). Intravenous, Non-Lyophilized (e.g., Liquid), 500 mg 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)
Injection, Omalizumab (Xolair), 5 mg 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)
Injection, Trastuzumab(Herceptin), 10mg J9355 55B31 – The documentation submitted was incomplete/insufficient.
  • The submitted medical records lack documentation to support the diagnosis identified.
55B44 – The submitted documentation was for the incorrect date of service.
 		 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 – (SNF) Bill Type 21x 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
Federally Qualified Health Centers (FQHC) - Behavior Health Treatments/Services Bill Type 77x; Revenue Code 0900 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/requires elements of the plan.
 Local Coverage Determination (LCD): Psychiatry and Psychology Services (L33632)

CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 13, Sections 10.2, 40, 40.3, and 170

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)
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

Revised 12/5/2023