Part B service-specific review -- outpatient rehabilitation services (CPT code 97110)

On August 17, 2020, medical review activity resumed, as directed by CMS, with implementation of post-payment service-specific medical record review.

First Coast is tasked with preventing inappropriate Medicare payments. One of the ways this is conducted is through medical review of claims. This helps to ensure that Medicare pays for services that are covered, coded correctly, and medically reasonable and necessary. 

High level results and top denial / partial denial reasons are listed below for the post-payment service specific reviews for outpatient rehabilitation code for Therapeutic activities CPT code 97110 that have been conducted by First Coast. If you have questions about your individual results, please contact the nurse reviewer assigned to your review assigned to your review for additional information. 

Outpatient rehabilitation services (August – November 2020 and August 2021)

Top full / partial denial reasons:

The most common reasons for denial or partial denials are the following:

• Level of care / incorrect coding – N/A
• Medical necessity – Documentation did not support medical necessity of services billed
  • Previous responses to therapy and ADL (activities of daily living) functional limitations were not clearly indicated in measurable terms
  • The patient’s progress was not written in measurable terms as it related to ADLs
• Insufficient documentation – The documentation provided was insufficient to support the services as billed to Medicare. Multiple attempts are made to correct these error types before completion of the review. Below are the most common denial reasons for insufficient documentation that we were not able to resolve:
  • Documentation did not support number of units billed based on treatment times.
  • Documentation did not include valid certifications or delayed certifications as outlined in the LCD.
  • Documentation did not include a certified plan of care (POC) and/or improvement / progress towards POC.
• Billing errors – N/A