Top denial/partial denial reasons and high-level results are listed below from each round of JH and JL Rehabilitation Therapy billed with KX modifier 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 of a certified/re-certified plan of care by the ordering/treating provider.
Documentation lacked evidence of a progress note/report every 10 visit to meet requirements.
Documentation lacked evidence that the service performed required the expertise of the licensed therapist.
Documentation did not support the frequency of electrical stimulation as medically reasonable and necessary.
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 requests (ADRs) - Documentation was not submitted to us in a timely manner to support the services billed to Medicare.
Therapy assistant utilization requirements not met - Documentation submitted for review did not support the requirements for a therapy assistant to perform the services.
Time not documented - Documentation submitted for review was insufficient to support the amount of time spent in the timed therapeutic service(s).
Incorrect date of service - Documentation submitted for review was for the incorrect date of service.
Billing errors - Upon receipt of the ADR request, the provider deemed the service was billed in error to Medicare.
Incorrect coding - Documentation submitted for review did not support the accurate amount of units billed, therefore the claim was changed to reflect the accurate number of units supported by the documentation.
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