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.

Comprehensive Outpatient Rehab Facility (CORF)

  • Units of service incorrectly coded
  • Wrong NPI listed
  • Missing physician order/intent and other critical documentation in chart (lab results, diagnostic reports, etc.)
  • Missing necessary therapy documentation

Critical Access Hospital (CAH) Outpatient Services

  • Insufficient documentation to support billed venipuncture
  • Missing physician order/intent only
  • CPT/HCPCS incorrectly coded
  • Missing therapy documentation (i.e. plan of care, certification/re-certification, progress report, etc.)
  • Missing the physician order/intent for the imaging or laboratory testing
  • Missing physician order/intent and other critical documentation in chart (lab results, diagnostic reports, visit notes, etc.)
  • Illegible signature without attestation or signature log
  • Units of service incorrectly coded

End Stage Renal Disease (ESRD)

  • Missing physician's signed orders for hemodialysis treatments and medications
  • Missing physician order/intent for other services provided during dialysis treatment
  • Missing physician orders and daily treatment records
  • Inpatient Psychiatric Facility (IPF) and Unit
  • CERT errors have been found specific to the following root causes:
  • Missing certification/recertification
  • Missing therapy documentation
  • No multidisciplinary treatment plan submitted
  • Wrong discharge status

Inpatient Prospective Payment System (IPPS): DRG Short Term

  • Inpatient not reasonable or necessary - 2 midnight expectation
  • Inpatient admission not reasonable or necessary as document does not support a medical need to admit
  • Inpatient not reasonable or necessary due to missing conservative treatment measures
  • Inpatient admission not reasonable and necessary as services could have been provided as outpatient
  • Inpatient admission not reasonable or necessary as documentation indicates social admit
  • DRG change (Diagnosis code related)
  • DRG change (Procedure code related)
  • No documentation was submitted
  • Missing MD orders/intent
  • Missing physician order/intent and other critical documentation in chart (lab results, diagnostic reports, etc.)
  • Missing preoperative office visit notes, preoperative radiology reports, and surgeon's exam
  • Missing radiologic reports
  • Procedure performed is justified in the record but the inpatient admission is not
  • MSP Error
  • Invasive procedure not medically necessary
  • Dual chamber pacemaker procedure not reasonable and necessary
  • Wrong discharge status
  • Admission date incorrect based on records

Inpatient Psychiatric Facility (IPF) and Unit

  • Missing certification/recertification
  • Missing therapy documentation
  • No multidisciplinary treatment plan submitted
  • Wrong discharge status

Inpatient Rehabilitation Facility (IRF) and Units

  • Missing documentation to support individual therapy
  • Insufficient individualized therapy minutes
  • Missing plan of care (POC)
  • Insufficient documentation to support the Inpatient Rehabilitation Facility stay
  • Insufficient therapy minutes
  • No supervision by a PMR physician
  • Missing documentation to support sudden discharge

Outpatient Prospective Payment System (OPPS), Laboratory (an FI), Ambulatory (Billing an FI)

  • Missing MD orders/intent
  • Missing physician order/intent and other critical documentation in chart (lab results, diagnostic reports, visit notes, etc.)
  • Therapy documentation (i.e. plan of care, certification/re-certification, progress report, etc.)
  • Records for wrong DOS submitted
  • Missing or illegible signature; missing attestation or signature log
  • Missing initial evaluation/plan of care
  • Units of service incorrectly coded
  • Missing documentation to support medical necessity
  • CPT/HCPC incorrectly coded

Rural Health Clinic (RHC)

  • No documentation was submitted
  • Illegible signature without attestation or signature log

Skilled Nursing Facility (SNF)

  • Units of service incorrectly coded
  • Incorrectly coded RUG based on documentation
  • Missing physician order/intent and other critical documentation in chart (lab results, diagnostic reports, etc.)
  • Missing valid physician's signed and dated certification/recertification
  • MDS issue (not submitted; ARD outside window)
  • MDS does not match the repository
  • Wrong NPI listed on claim

Highlights

  • CMS implemented the Comprehensive Error Rate Testing (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.
  • 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.

 

Last Updated Feb 24, 2020