Article Detail - JE Part B

What is CERT:

• Created to measure error rate of improper Medicare payments for Fee-For-Service programs.
• CERT contractor - Empower AI
• Goal is reducing improper payment rate measured by CERT program.
• Submit documentation in 45 days.
• Findings sent to MAC to educate providers.
• CMS expectation - Providers and labs and radiology providers work together to get necessary records.

What did their claims reviews find regarding clinical lab claims?

• Laboratory services were frequently denied for missing documentation:
  • Missing or incomplete orders
  • Documentation missing necessary to support medical necessity or intent.
  • Results of tests billed.
  • Basic billing requirements such as missing signatures

Make sure your billing staff is sending all required information for CERT reviews to reduce your staff workload.

Resources

• CMS What’s the Comprehensive Error Rate Testing (CERT) Program?
• CMS Medicare Learning Network MLN909221 - Complying with Documentation Requirements for Lab Services
• CMS Internet Only Manual (IOM) Publication 100-02 Medicare Benefit Policy Manual Chapter 15 Section 80.6
• Physician’s Orders for Diagnostic Laboratory Tests