Common CERT Errors

Noridian needs your help. To combat the national Comprehensive Error Rate Testing (CERT) error rate, we are asking associations, facilities and service providers to share this information with staff and affiliates, including compliance and business office management, physicians and practitioners, and all other individuals involved in patient care, coding, billing and medical record keeping. Together we can make a difference. View CERT Highlights.

CERT errors have been found specific to the root causes indicated in each section below.

Ambulance

Transportation codes, such as HCPCS A0425, A0427, A0428 and A0429, were not supported due to insufficient documentation and medical necessity.

  • Ambulance services not reasonable and necessary: submitted documentation does not support that beneficiary could not have been safely transported by another method
  • Missing or illegible signature; missing attestation or signature log and documentation to support medical necessity
  • Missing treating physician's certification statement relevant to ambulance transport for billed DOS
  • Missing a copy of the Assignment of Benefits (AOB) or a legible signature on the AOB to authorize provider of ambulance services to bill Medicare, that was signed by beneficiary or responsible party; or documentation to support that no other qualified person was willing or available to sign AOB on behalf of beneficiary

Ambulatory Surgical Center (ASC)

Surgical codes, such as CPTs 29827 and 64635, were not supported due to insufficient documentation and medical necessity.

  • Procedure - Missing supportive documentation (i.e. pre-procedural, conservative measures, pain assessment, evaluation, clinical documentation, etc.)
  • Procedure - Documentation supports the addition/change of a modifier
  • Missing documentation to support medical necessity
  • Missing supportive documentation for injection/infusion services (i.e. pre-procedural, conservative measures, pain assessment, etc.)

Anesthesia & Pain Management

Anesthesiology and Pain Management services, such as CPTs 01992, 93312, Evaluation and Management (E/M) codes, G codes, laboratory codes, CPTs 64635 and 64636, were not supported due to insufficient documentation, medical necessity and incorrect coding.

  • Imaging or Laboratory test - Missing physician order/intent and supportive documentation (i.e. lab results, diagnostic reports, visit notes, clinical documentation, etc.)
  • Imaging or Laboratory test - Missing supportive documentation (i.e. daily notes, progress notes, evaluation, clinical documentation, etc.)
  • Imaging or Laboratory test - Missing the physician order/intent only
  • Imaging or Laboratory test - Documentation supports CPT/HCPCS code change
  • Imaging or Laboratory test - Missing results/report only
  • Injection/Infusion Services - Documentation does not support medical necessity
  • E/M - Documentation supports CPT/HCPCS code change (down code)
  • Missing supportive documentation (i.e. pre-procedural, conservative measures, pain assessment, evaluation, clinical documentation, etc.)

Cardiology

Services provided in a Cardiology specialty, such as various E/M codes, laboratory codes, injections and CPT 93306, were not supported due to insufficient documentation, no documentation and incorrect coding.

  • E/M - Documentation supports CPT/HCPCS code change (down code)
  • E/M - Missing supportive documentation (i.e. daily notes, progress notes, evaluation, clinical documentation, etc.)
  • Missing physician order/intent and supportive documentation (i.e. lab results, diagnostic reports, visit notes, clinical documentation, etc.)
  • Imaging or Laboratory test - Missing supportive documentation (i.e. daily notes, progress notes, evaluation, clinical documentation, etc.)
  • Missing or illegible signature; missing attestation or signature log
  • Services billed were not rendered
  • Missing physician order/intent only
  • Missing documentation of billed injection/infusion services
  • Missing progress note
  • Documentation supports CPT/HCPCS code change

Chiropractic

Chiropractic services, such as CPTs 98940, 98941 and 98942, were not supported due to insufficient documentation.

  • Missing or illegible signature; missing attestation or signature log
  • Missing supportive documentation
  • Pre-procedural
  • Initial evaluation
  • Plan of care
  • Certification/recertification
  • Specific area of body treatment was performed
  • Progress note
  • Conservative measures
  • Pain assessment
  • Other clinical documentation

End Stage Renal Disease (ESRD)

Dialysis services, such as CPTs 90935 and 90960, were not supported due to insufficient documentation and incorrect coding.

  • Dialysis - Missing supportive documentation (i.e. daily treatment records, progress notes, etc.)
  • Documentation supports CPT/HCPCS code change

Evaluation and Management

Multiple E/M codes, were not supported due to insufficient documentation and incorrect coding.

  • Missing a valid physician order as required by regulation, interpretive manual or LCD (includes physician signature or date)
  • Documentation submitted does not adequately describe service defined by CPT code, HCPCS code and/or HCPCS modifier billed
  • Does not meet any required key element for billed E/M service but meets for lower level E/M service
  • Does not meet medical decision making key element for billed E/M service level
  • Missing hospital record
  • Documentation supports higher level E/M service than what was billed
  • Missing signed office note for claim date
  • Provider indicates that a record could not be found for specified dates of service
  • Though a valid ICD-9/ICD-10 code(s) was submitted, ICD-9/ICD-10 code(s) alone was insufficient information
  • Service does not meet definition of critical care

Independent Diagnostic Testing Facility (IDTF)

Services provided in an IDTF, were not supported due to insufficient documentation.

  • Missing supportive documentation (i.e. daily notes, progress notes, evaluation, clinical documentation, etc.) and an attestation
  • Missing supportive documentation (i.e. daily notes, progress notes, evaluation, clinical documentation, etc.)
  • Missing physician order/intent and supportive documentation (i.e. lab results, diagnostic reports, visit notes, clinical documentation, etc.)

Laboratory

Multiple laboratory codes were not supported due to insufficient documentation, medical necessity and incorrect coding.

  • Missing physician order/intent and supportive documentation (i.e. lab results, diagnostic reports, visit notes, clinical documentation, etc.)
  • Missing supportive documentation (i.e. daily notes, progress notes, evaluation, clinical documentation, etc.)
  • No medical records were submitted
  • Missing results/report and supportive documentation (i.e. clinical documentation, progress notes, evaluation, etc.)
  • Missing results/report only
  • Venipuncture - Documentation does not support medical necessity
  • Documentation supports CPT/HCPCS code change
  • Documentation does not support medical necessity
  • Missing the physician order/intent only
  • Services billed were not rendered

Mental Health

Mental health related services were not supported due to insufficient documentation and incorrect coding.

  • Therapy - Missing supportive documentation (i.e. plan of care, certification/re-certification, progress report, conservative treatments, etc.)
  • E/M - Documentation supports CPT/HCPCS code change (down code)
  • E/M - Missing supportive documentation (i.e. daily notes, progress notes, evaluation, clinical documentation, etc.)

Non Physician Practitioner (NPP)

Services provided by NPPs were not supported due to insufficient documentation and incorrect coding.

  • Procedure - Missing supportive documentation (i.e. pre-procedural, conservative measures, pain assessment, evaluation, clinical documentation, etc.)
  • Procedure - Missing or illegible signature; missing attestation or signature log
  • Injection/Infusion Services - Missing supportive documentation (i.e. pre-procedural, conservative measures, pain assessment, etc.)
  • Therapy - Missing supportive documentation (i.e. plan of care, certification/re-certification, progress report, conservative treatments, etc.)
  • Imaging or Laboratory test - Missing supportive documentation (i.e. daily notes, progress notes, evaluation, clinical documentation, etc.)
  • Imaging or Laboratory test - Missing or illegible signature; missing attestation or signature log
  • Imaging or Laboratory test - Documentation supports CPT/HCPCS code change
  • Imaging or Laboratory test - Missing physician order/intent and supportive documentation (i.e. lab results, diagnostic reports, visit notes, clinical documentation, etc.)
  • E/M - Documentation supports CPT/HCPCS code change (down or up code)
  • E/M - Documentation submitted does not adequately describe service defined by CPT code, HCPCS code, a HCPCS modifier billed.
  • Service billed is a bundled service but was billed for separate payment

Oncology/Hematology

Services provided in an Oncology/Hematology specialty, such as various laboratory, therapy, CPT 96409, CPT 96413, E/Ms, HCPCS G6015 and injection/infusion were not supported due to insufficient documentation and incorrect coding.

  • E/M - Missing supportive documentation (i.e. daily notes, progress notes, evaluation, clinical documentation, etc.)
  • E/M - Documentation supports CPT/HCPCS code change (down code)
  • Injection/Infusion Services - Documentation does not support medical necessity
  • Injection/Infusion Services - Missing physician order/intent only
  • Injection/Infusion Services - Documentation supports UOS change
  • Imaging or Laboratory test - Documentation supports CPT/HCPCS code change
  • Service billed is a bundled service but was billed for separate payment

Optometry/Ophthalmology

Services provided in an Optometry/Ophthalmology specialty, such as E/Ms, CPTs 67500, 67228, 92020, 92014, 92235 and HCPCS J9035 were not supported due to insufficient documentation, medical necessity and incorrect coding.

  • E/M - Documentation supports CPT/HCPCS code change (down code)
  • Optometry - Documentation submitted does not adequately describe the service defined by CPT code, HCPCS code, a HCPCS modifier billed.
  • Optometry - Documentation supports the addition/change of a modifier
  • Imaging or Laboratory test - Missing results/report only

Outpatient Therapy

Services provided in an Outpatient Therapy specialty, such as E/Ms, CPTs 97110, 97035, 97140 and HCPCS G0283 were not supported due to insufficient documentation and incorrect coding.

  • Therapy - Missing supportive documentation (i.e. plan of care, certification/re-certification, progress report, conservative treatments, etc.)
  • Therapy - Documentation supports UOS change
  • E/M - Missing supportive documentation (i.e. daily notes, progress notes, evaluation, clinical documentation, etc.)
  • Procedure - Missing supportive documentation (i.e. pre-procedural, conservative measures, pain assessment, evaluation, clinical documentation, etc.)

Podiatry

Services provided in a Podiatry specialty, such as E/Ms, CPT 29425 and HCPCS Q4038 were not supported due to insufficient documentation and incorrect coding.

  • E/M - Documentation supports CPT/HCPCS code change (down or up code)
  • Procedure - Missing supportive documentation (i.e. pre-procedural, conservative measures, pain assessment, evaluation, clinical documentation, etc.)

Radiology and Radiation Oncology

Services for Radiology and Radiation Oncology, such as various therapy and standard/advanced imaging related to chest, breast, nuclear medicine, CAT/CT/CTA and musculoskeletal tests were not supported due to insufficient documentation.

  • Imaging or Laboratory test - Missing physician order/intent and supportive documentation (i.e. lab results, diagnostic reports, visit notes, clinical documentation, etc.)
  • Imaging or Laboratory test - Missing results/report only
  • Imaging or Laboratory test - Missing supportive documentation (i.e. daily notes, progress notes, evaluation, clinical documentation, etc.)
  • Imaging or Laboratory test - Missing physician order/intent only
  • Radiation Oncology - Missing supportive therapy documentation (i.e. plan of care, certification/re-certification, progress report, conservative treatments, etc.)

Surgery

Major and minor procedures, such as musculoskeletal, skin, orthopedic and other services were not supported due to insufficient documentation, medical necessity and incorrect coding.

  • Missing supportive documentation (i.e. pre-procedural, conservative measures, pain assessment, evaluation, clinical documentation, etc.)
  • Documentation supports UOS change
  • Service billed is a bundled service but was billed for separate payment
  • Documentation supports addition/change of a modifier
  • Missing or illegible signature; missing attestation or signature log

Highlights

  • CMS implemented the CERT program to measure improper payments in the Medicare Fee-for-Service (FFS) program. CERT is designed to comply with the Improper Payments Information Act (IPIA) of 2002, as amended by the Improper Payments Elimination and Recovery Improvement Act (IPERIA) of 2012.
  • CERT is a requirement and mandated by law. Therefore, it is vital that all Medicare service providers are compliant with submitting the necessary information to support the coverage, coding and billing of services being submitted to Medicare for reimbursement.
  • Requests for records from the CERT Contractor do not pose any Health Insurance Portability and Accountability Act (HIPAA) vulnerabilities. Also, beneficiary authorization is not needed to release information for the request because authorization has already been given to release necessary medical information to process the claim.
  • A response to a CERT request for records is required even if records for the sampled beneficiary dates of service cannot be provided. In accordance with Social Security Act Sections 1156 [42 U.S.C. 1320C-5], 1833 [42 U.S.C. 13951](e), and 1815 [42 U.S.C. 1395g] (a), as a Medicare provider, documentation and medical records must be provided to the CERT contractor upon request to support claims for Medicare services. It is the billing providers responsibility to obtain additional supporting documentation from a third party (hospital, clinic, nursing home, etc.), as necessary. Providing medical records of Medicare patients to the CERT contractor is within the scope of compliance with the Health Insurance Portability and Accountability Act (HIPAA).
  • The Medicare FFS Supplemental Improper Payment Data for the 2017 report has been published on the CMS website. It will provide a lot of information that providers could use to identify error trends.

 

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