Comprehensive Error Rate Testing

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CERT Error Focus - Physicial Medicine and Rehabilitation Procedures and Modalities - CPT 97001-97546

In our continuing effort to increase the awareness of all Medicare providers regarding issues found as a result of Comprehensive Error Rate Testing (CERT) reviews, we have been focusing on specific services that contribute to our CERT error rate. Our focus this month is on incorrect coding and insufficient documentation issues related to physical medicine and rehabilitation, specifically Current Procedural Terminology (CPT) procedure codes 97035-97140.

Analysis of our current CERT error findings (claims submitted 04/01/05-03/31/06) indicates that insufficient documentation issues are the cause of errors in the majority of these cases, followed by instances of incorrect coding (ex., up coding or down coding). Oftentimes, the CERT contractor is unable to obtain the needed information even after additional follow-up contacts to the provider. Below are examples of actual CERT review comments received for these claims.

Insufficient Documentation

• Need copies of physical therapy plan of treatment, physician order/certification/recertification for physical therapy services and notes to include minutes for each billed modality for date of service billed. Per the Social Security Act (SSA) 1833(e) and Internet-Only Manual (IOM) Pub. 100-02, Chapter 15, Section 220, missing physical therapy plan of treatment and physician order/certification/recertification for physical therapy services for date of service. Submitted documentation consists of progress notes without clear notation of modalities and minutes.
• Missing initial physical therapy evaluation and the physician certified treatment plan for care for PT treatment(s) done, per Local Coverage Determination (LCD) for Physical Medicine and Rehabilitation Procedures and Modalities PHYSMED-009 V7 (Rev. Eff. 07/25/2005).
• Need Physician signed order for treatment, and a plan of care with frequency and duration of services provided including goals. Received additional note from provider stating, "Charges have been backed off, no signature on 'Plan of Care'. Refund done to Medicare for all physical therapy dates of service."

Service Incorrectly Coded

• Submitted with CPT 97110, therapeutic procedure, one or more areas, each 15 minutes, (2) units of service = 30 minutes. Documentation does not support 30 minutes of therapy provided. Time noted on bottom on progress note dated 03/21/2005 has an entry for 03/24/2005 as 11:20 to 11:30. Change code from CPT 97110, (2) units of service to 97110, (1) unit of service.
• Per SSA 1833(e), CPT 2005 and IOM Pub. 100-4, Chapter 5, Sections 20.2 and 20.3, which states, "For any single CPT code, providers bill a single 15-minute unit for treatment greater than or equal to 8 minutes and less than 23 minutes. If the duration of a single modality or procedure is greater than or equal to 23 minutes, to less than 38 minutes, then 2 units should be billed." Submitted with CPT code 97140, manual therapy techniques per 15 minutes, (2) units of service = 30 minutes. Documentation supports 22 minutes of manual therapy technique provided. Change code from 97140(2) units of service to 97140(1) unit of service.

Providers must be aware of documentation requirements when billing physical therapy services to Medicare Part B. The patient's medical records should be legible, with a plan of care that incorporates the skilled treatment elements that are expected to result in improvement of the patient's physical and functional limitations in a reasonable and generally predictable period of time or the evaluation services must be necessary to establish a safe and effective maintenance regimen required in connection with a specific disease; with clear goals defined. In addition, the type, amount, frequency, and duration of services must be medically necessary for the patient's condition under accepted medical, physical therapy, and occupational therapy practice standards, and relate directly to a written treatment plan.

Proper documentation of services billed to Medicare is crucial in order to meet CMS' error rate reduction expectations, and WPS continues to identify problem areas contributing most significantly to our jurisdiction's error rate. Continued cooperation from providers in proper billing and documentation of services billed to Medicare is essential in order to reach these goals.

For more information regarding the CERT program and other issues related to CERT review findings, please visit our website. If you have questions related to the CERT process or a specific CERT sampled claim, you may e-mail us at medicareadmin@wpsic.com. Be sure to include "CERT Question" in the subject line. Please also include your full name, telephone number, and Provider Identification Number (if available) in the body of the e-mail. This will assure a prompt and accurate reply to your question.

When e-mailing WPS Medicare, please do not include sensitive information. If your question pertains to a specific claim, include the Internal Control Number (ICN), not your patient's Medicare Health Insurance Claim (HIC) Number.

For more information regarding Medicare coverage of physical medicine and rehabilitation services, please refer to LCD PHYSMED-009 and National Coverage Policy (NCP) PHYSMED-001 on our WPS Medicare Website.