Top denial/partial denial reasons and high-level results are listed below from each round of JH and JL psychotherapy TPE reviews that have been conducted thus far by our Medical Review. If you have questions about your individual results, please contact the nurse reviewer assigned to your review for additional information. Additional rounds of review will be utilized when the targeted topic demonstrates a continued need for review with newly identified providers.
The most common reasons for denial or partial denials are the following:
Medical necessity - Documentation submitted for review was lacking evidence of medical necessity for the following reasons:
Documentation was lacking evidence that the practitioner was performing the service within their scope of practice.
Documentation was lacking evidence to support the service as medically reasonable and necessary psychotherapy service.
Documentation was lacking evidence to support the amount of time spent performing psychotherapy service.
Insufficient documentation - Documentation submitted for review was insufficient to support the services as billed to Medicare. Our Medical Review makes multiple attempts to correct these error types before completion of the review. Below is the following top denial/partial denial reason(s) for insufficient documentation that we were not able to resolve:
No response to additional documentation request (ADRs) - Documentation was not submitted in a timely manner to support the services billed to Medicare.
Incorrect coding - Documentation submitted for review did not support the accurate number of units billed based on time spent in performing service and therefore was recoded to the appropriate level of service based on time.
Incident to requirements - Documentation submitted for review did not support sufficient evidence of physician supervision required to bill under the physician to Medicare.
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