Targeted probe and educate (TPE) round results: Rehabilitation services outpatient (KX modifier)

Top denial / partial denial reasons and high-level results are listed below from each round of rehabilitation services outpatient TPE reviews that have been conducted thus far by 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.

Top denial / partial denial reasons

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

• Medical necessity - The documentation submitted does not support medical necessity as listed in coverage requirements.
• Insufficient documentation - Insufficient documentation was provided to support the services as billed to Medicare. Medical Review makes multiple attempts to correct these error types before completion of the review. Below are the following denial reasons for insufficient documentation that we were not able to resolve:
  • Documentation was lacking evidence of a certified / re-certified plan of care by the ordering / treating provider. (No evidence of delayed certification or attempts to obtain delayed certification)
  • Documentation missing diagnoses and/or long-term goals in plan of care.
  • Documentation lacked evidence of a progress notes / report every 10 visit to meet requirements and/or signed by the PT.
  • Documentation lacked evidence that the service performed required the expertise of the licensed therapist.
  • Insufficient documentation to support the units billed outcomes, or therapeutic interventions.
  • Documentation submitted did not support a valid plan of care.
  • Documentation submitted did not support the billed number of units and were reduced to the number of units supported.
  • Documentation submitted did not support the billed date of service.
  • Documentation submitted lacked a signed certification/recertification.
  • Documentation submitted lacked evidence that the service was performed by a qualified provider.
  • Documentation submitted did not support a valid plan of care due to missing components.
  • Non-response to documentation request.

Round results