Medicare Coverage mcd feedback | coverage
home | help | basket
Search Indexes Reports Download
Indexes Home > Articles by State > List of Articles for United Government Services,
LLC (00453, FI) > View Article
Article for Outpatient Therapy and Inpatient Rehabilitation Probe and
Targeted Medical Review (TMR) Audits (A38537)
Jump to Section...
Please note: If you are printing this document and it is truncated on the
right margin, please try printing landscape.
Contractor Name back to top
United Government Services, LLC
Contractor Number back to top
Contractor Type back to top
Article ID Number back to top
Article Type back to top
Key Article back to top
Article Title back to top
Outpatient Therapy and Inpatient Rehabilitation Probe and Targeted
Medical Review (TMR) Audits
Primary Geographic Jurisdiction back to top
Secondary Geographic Jurisdiction back to top
Original Article Effective Date back to top
Article Revision Effective Date back to top
Article Text back to top
Outpatient Therapy and Inpatient Rehabilitation Probe and Targeted
Medical Review (TMR) Audits
Frequently Asked Questions
Outpatient Therapy under Medicare Part B
Note: Sites of service for Medicare Part B include therapy services in Outpatient
Hospital Departments (including therapy in the ER or Observation Room),
Outpatient Therapy Facilities, Comprehensive Outpatient Rehabilitation
Facilities (CORF), outpatient services provided in a Nursing Home, and therapy
services to SNF residents covered under the Part B benefit.
Q1: Knowing that many outpatient audits have now taken place, can you
provide any new changes in significant issues.
A1: An area that continues to require attention is the documentation of
minutes for each modality and therapeutic intervention. There should
be documentation of minutes spent delivering the service for each
HCPCS/CPT billed. Question #3 addresses other common denials.
Q2. What criteria determine who is audited?
A2: UGS follows the Progressive Corrective Action (PCA) Process
implemented by CMS in August of 2000. The PCA Process requires
contractors to base their reviews on data analysis. However, as before,
reviews may also occur in response to provider or beneficiary
complaints, fraud alerts or CMS referrals.
UGS’ Data and Statistics Unit (DSU) provides ongoing data analysis. All
data is analyzed and prioritized to identify those services that
represent the greatest potential Medicare program vulnerabilities. Paid
claims data is reviewed and compared to like providers within all UGS
workloads, as well as to like providers within the Region, State, or
Nation. Providers or services which appear to be a statistical outlier
may then be selected for a limited review called a Probe Review. The
results of the Probe Review will determine if the provider continues on
Targeted Medical Review or if no further action is required beyond
An example of data analysis that may be conducted based on input
from CMS is the utilization of CPT code 97755 – Physical performance
test or measurement. This is a fairly new CPT code for therapy and CMS
has noticed a high utilization of this code. Based on data analysis
conducted by UGS, it is possible that those providers demonstrating
high utilization of this code compared to their peers will be selected for
a Probe Review.
Another example may be data that is run on an untimed code such as
97001 (physical therapy evaluation). Providers identified as outliers in
the billing of multiple units for this untimed code may be placed on
Probe Review to determine if a problem exists that requires
Q3: Are there specific areas of documentation or billing procedures that are
areas of concern during Outpatient Therapy review?
A3: Frequently, providers are not sending in all documentation
requested; daily documentation or the evaluation may be missing. It is
imperative that all items listed on the Additional Development Request
(ADR) be sent when requested as part of a probe or TMR. The
submitted documentation is reviewed for medical necessity and
evidence of significant functional progress in a timely manner. (For
information regarding medical necessity coverage for therapy, refer to
the new therapy coverage section of the CMS manuals in CR 3648,
Transmittal 36 issued June 24, 2005 at
http://www.cms.hhs.gov/manuals/pm_trans/R36BP.pdf.) The documentation
submitted must paint a complete picture of the patient, the progress of
the functional limitations/impairments. The documentation must also
show that skilled therapy is needed and provided. An exercise or
treatment log that lists repetitive activities does not alone demonstrate
that skilled therapy is provided. In addition to review for medical
necessity, the claim charges are compared to the documentation
submitted, matching HCPCS/CPT codes and units billed to the
documented treatment and minutes.
Frequent denials continue for many of the same reasons as those
published in our Medicare Memo article dated September 23, 2005,
“Common Therapy Denial Reasons for Outpatient and Skilled Nursing Facility
(SNF)”. Refer to the article for education regarding common therapy
denials such as “Insufficient Information”, “Not Reasonable and
Necessary”, and “Documentation of Minutes Does Not Support Number
of Units Billed”.
Inpatient Rehabilitation Facility (IRF) Audits
Q1: What issues are you finding during IRF audits?
A1: Recent probe audits were completed for CMGs in the categories of
“Replacement of Lower Extremity Joint” and “Miscellaneous”. Many of
the joint replacements do not meet the requirements for IRF level of
care. Most of the “miscellaneous” reviewed to date have been
inappropriate for this level of care as well. These have included
patients admitted for debility and deconditioning, s/p pneumonia, s/p
dehydration and COPD.
One of the audit observations relates to the 3-hour guideline. CMS has
instructed that “the general threshold for establishing the need for IRF
services is that the patient must require and receive at least three
hours a day of therapy (PT, OT, SLP or orthotics/ prosthetics) no less
than five days a week”. The patient must demonstrate a need for this
level of intense therapy. In addition, the therapy that is provided must
meet the definition of “skilled”: services that only a PT, OT, SLP or in
some cases, an orthotist/prosthetist, can safely and effectively
perform. Audit findings demonstrate that many IRF patients are not
receiving 3 hours of therapy, 5 days a week. In addition, audits have
shown that therapy services, which did not meet the reasonable and
necessary (R&N) therapy requirements, have been counted toward the
3-hour guideline. For example, SLP to address very high level cognitive
reasoning would not be R&N for the patient to return to selfcare and
ADLs, therefore, the minutes to provide this type of treatment would
not apply toward the 3-hour guideline the patient back to safe selfcare
and ADLs that are meaningful for the patient in the intended discharge
environment. Once the patient no longer requires the skilled
intervention of a therapist to safely complete a task (with or without
assistance), that selfcare or ADL should be removed from the therapy
plan of treatment. Audits have found that as patients become more
independent in various selfcare and ADLs, more time is being spent on
therapeutic exercise. Without a direct link to a specific functional
deficit that requires continued skilled therapy, this type of therapeutic
exercise would be considered “general conditioning”, and would not
meet the Medicare requirements for “Reasonable and Necessary” (and
therefore would not count toward the 3-hour guideline).
Q2: Please provide guidance regarding documentation to support the need for
24-hour rehabilitation nursing care.
A2: The patient must require the 24 hour availability of a registered
nurse with specialized training or experience in rehabilitation.
Document not only the patient examination elements (e.g., BP,
continence, safety awareness), but also an assessment of the impact
your findings have on the patient’s rehabilitation and the education &
treatment provided. Include ongoing assessment of the effects of
treatment implemented by nursing and other team members including
carryover of self-care, mobility or cognitive/swallowing techniques
used by therapists. Patient and caregiver education and training as
well as FIM scoring should be included. Documentation to support an
interdisciplinary coordinated team approach is required.
Q3: What role does the clinical team conference note play in your chart review/
determination of medical necessity?
A3: The clinical team conference is very important and should be lead
by the physician, as the IRF team leader. Team conference
documentation is the blueprint to demonstrate the interdisciplinary
nature of the program, which includes not only identifying problems,
but also a discussion of their resolution. It is particularly valuable in
determining medical necessity of continued stay.
Q4: How important is including the preadmission screen when submitting the
medical record for review?
A4: The preadmission screen is possibly the most important document
to support the need for admission to an IRF. If preadmission screening
information indicated that the patient had the medical and
rehabilitation needs and potential that only an IRF can provide, then a
period of an IRF assessment could be covered. The documentation
should demonstrate “why” the patient requires 24 hour MD
supervision, rehab nursing, intensity (3 hours) of therapy, etc. Just
writing on the pre-admission screen and MD notes that “Patient
requires daily MD visits, rehab nursing and 3 hours of therapy” does
not tell the reviewer “why” and does not justify admission to an IRF.
Q5: Understanding that groups in an IRF should not be used extensively and
that they cannot take the place of individual therapy, can you provide any
specific suggestions as to how a facility might document and support
appropriate use of groups?
A5: Document the purpose of the group, how many are in the group,
the patient’s participation and progress in the group. Avoid limiting any
day’s treatment to only group therapy. Documentation should show
that the patient is a willing and motivated participant, attends and
actively participates, can benefit from therapy that is not 1:1 in nature
and that the patient is able to learn from the clinician leading the
group. We also look for explanations that the patient can learn by
observing other group members and can respond appropriately to
feedback and perform activities incorporating the feedback. The
documentation must support that group therapy is skilled, reasonable
and necessary and related to the individual plan of treatment.
Audits have shown significant use of group without documentation of
why group would be beneficial to the patient. In addition, group
activities must be meaningful and R&N for the patient’s condition. For
example, UE strengthening exercises for a patient with 4+ or 5/5 UE
strength would not be considered R&N when there is no documentation
that UE weakness is impairing the patient’s ability to be independent in
ADLs/selfcares; or w/c mobility activities would not be R&N when the
patient’s goal is ambulation.
Coverage Topic back to top
Physical, Occupational, and Speech Therapy
No Coding Information has been entered in this section of the
There is no Other Information for this article.
Read the Article Disclaimer
Note: To view PDFs, please download and install Adobe Acrobat Reader.
Add to basket | Email this to a friend | New Search