Common CERT Errors

 

Ambulance

CERT errors have been found specific to services incorrectly coded, insufficient documentation and medical necessity. Transportation codes, such as A0425, A0427, A0428 and A0429, were not supported due to:

  • Missing a valid physician order as required by regulation, interpretive manual or Local Coverage Determination (LCD) (includes physician signature or date)
  • Though a valid ICD-9/ICD-10 code(s) was submitted, the ICD-9/ICD-10 code(s) alone was insufficient information
  • Records for the wrong dates of service were submitted
  • No signature log or attestation submitted
  • Documentation submitted does not adequately describe the service defined by the CPT code, HCPCS code and/or HCPCS modifier billed

 

Ambulatory Surgical Center

CERT errors have been found specific to insufficient documentation and medical necessity. Integumentary surgery repair codes, such as 15823, were not supported due to:

  • Though a valid ICD-9/ICD-10 code(s) was submitted, the ICD-9/ICD-10 code(s) alone was insufficient information to support the services billed
  • Documentation submitted does not adequately describe the service defined by the CPT code, HCPCS code and/or HCPCS modifier billed
  • Missing clear front and side eye photos that document obvious dermatochalasis, ptosis or brow ptosis
  • Missing a signature attestation statement for the illegibly signed visual field test reports for both eyes taped and un-taped

 

Anesthesia & Pain Management

CERT errors have been found specific to insufficient documentation and medical necessity. Laboratory and G codes, were not supported due to:

  • Documentation submitted does not adequately describe the service defined by the CPT code, HCPCS code and/or HCPCS modifier billed
  • Missing a valid physician order as required by regulation, interpretive manual or LCD (includes physician signature or date)
  • Though a valid ICD-9/ICD-10 code(s) was submitted, the ICD-9/ICD-10 code(s) alone was insufficient information
  • Records for the wrong dates of service were submitted
  • Missing diagnostic test/lab results

 

Cardiology

CERT errors have been found specific to services incorrectly coded and insufficient documentation. Evaluation and Management (E/M), laboratory and other codes, were not supported due to:

  • Does not meet any required key element for billed E/M service but meets for lower level E/M service
  • Service was incorrectly coded as document supports a higher level E/M service than what was billed
  • Though a valid ICD-9/ICD-10 code(s) was submitted, the ICD-9/ICD-10 code(s) alone was insufficient information
  • Provider indicates they are unable to locate this patient/beneficiary
  • Missing a valid physician order as required by regulation, interpretive manual or LCD (includes physician signature or date)
  • Does not meet medical decision making key element for billed E/M service level

 

Chiropractic

CERT errors have been found specific to services incorrectly coded and insufficient documentation. Chiropractic Manipulative Treatment (CMT) codes, such as 98940, 98941 and 98942, were not supported due to:

  • No chiropractic treatment plan documented to support a plan of care
  • Documentation does not support the performance of CMT on the billed dates of service
  • The chiropractic medical records are illegible or abbreviations used cannot be determined
  • Though a valid ICD-9/ICD-10 code(s) was submitted, the ICD-9/ICD-10 code(s) alone was insufficient information
  • Records for the wrong dates of service were submitted

 

End Stage Renal Disease

CERT errors have been found specific to services incorrectly coded. Dialysis codes, such as 90960, were not supported due to:

  • Submitted documentation supports CPT 90961 (two-three face-to-face visits) or CPT 90962 (one face-to-face visit) rather than 90960 (four or more face-to-face visit)

 

Evaluation and Management (E/M)

CERT errors have been found specific to services incorrectly coded and insufficient documentation. Multiple E/M codes were not supported due to:

  • Missing a valid physician order as required by regulation, interpretive manual or LCD (includes physician signature or date)
  • Documentation submitted does not adequately describe the service defined by the 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 the specified dates of service
  • Though a valid ICD-9/ICD-10 code(s) was submitted, the ICD-9/ICD-10 code(s) alone was insufficient information
  • Service does not meet definition of critical care

 

Family Practice

CERT errors have been found specific to services incorrectly coded and insufficient documentation. Multiple services provided in a family practice setting, such as E/M, pulmonary and cardiovascular codes, were not supported due to:

  • Missing a valid physician order as required by regulation, interpretive manual or LCD (includes physician signature or date)
  • Documentation submitted does not adequately describe the service defined by the 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
  • Though a valid ICD-9/ICD-10 code(s) was submitted, the ICD-9/ICD-10 code(s) alone was insufficient information
  • Provider indicates the beneficiary is not their patient
  • Records for the wrong dates of service were submitted

 

Laboratory

CERT errors have been found specific to services incorrectly coded and insufficient documentation. Multiple laboratory codes were not supported due to:

  • Missing a valid physician order as required by regulation, interpretive manual or LCD (includes physician signature or date)
  • Documentation submitted does not adequately describe the service defined by the CPT code, HCPCS code and/or HCPCS modifier billed
  • Missing hospital record
  • Provider indicates they are unable to locate this patient/beneficiary
  • Documentation is missing identification of beneficiary name
  • Though a valid ICD-9/ICD-10 code(s) was submitted, the ICD-9/ICD-10 code(s) alone was insufficient information

 

Mental Health

CERT errors have been found specific to insufficient documentation. Psychotherapy codes, such as 90832 and 90834, were not supported due to:

  • Missing a valid plan of care (including physician signature and date)
  • Psychotherapy service documentation has no time in minutes or in and out time documented in record
  • Documentation submitted does not adequately describe the service defined by the CPT code, HCPCS code and/or HCPCS modifier billed

 

Nephrology

CERT errors have been found specific to services incorrectly coded and insufficient documentation to support medical necessity. E/M, radiology and dialysis codes, such as 99233, 75962 and 90960, were not supported due to:

  • Does not meet any required key element for billed E/M service but meets for lower level E/M service
  • Though a valid ICD-9/ICD-10 code(s) was submitted, the ICD-9/ICD-10 code(s) alone was insufficient information
  • Does not meet type of history key element for billed E/M service level
  • No medical records were submitted (only facility billing information)

 

Nonphysician Practitioners

CERT errors have been found specific to services incorrectly coded and insufficient documentation. Services provided by Nurse Practitioners, Occupational Therapists in Private Practice and Portable X-ray Suppliers, such as therapy, E/M, radiology and injection codes, were not supported due to:

  • Certification of therapy plan of treatment not signed by the physician listed on the claim as ordering/referring
  • Missing a valid physician order as required by regulation, interpretive manual or LCD (includes physician signature or date)
  • Documentation submitted does not adequately describe the service defined by the 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
  • Documentation meets higher level E/M service than what was billed
  • Though a valid ICD-9/ICD-10 code(s) was submitted, the ICD-9/ICD-10 code(s) alone was insufficient information
  • Missing therapy certification/recertification
  • Missing therapy initial evaluation
  • Missing therapy minutes
  • Missing medical doctor's order for therapy
  • Missing valid plan of care (including physician signature and date)

 

Oncology/Hematology

CERT errors have been found specific to insufficient documentation and services incorrectly coded. Oncology/Hematology services, such as E/M, biologic agent administration, laboratory services and injections, were not supported due to:

  • Missing a valid physician order as required by regulation, interpretive manual or LCD (includes physician signature or date)
  • Service does not meet definition of critical care
  • Does not meet any required key element for billed E/M service but meets for lower level E/M service
  • Does not meet type of history key element for billed E/M service level
  • Though a valid ICD-9/ICD-10 code(s) was submitted, the ICD-9/ICD-10 code(s) alone was insufficient information
  • Documentation submitted does not adequately describe the service defined by the CPT code, HCPCS code and/or HCPCS modifier billed

 

Optometry/Ophthalmology

CERT errors have been found specific to insufficient documentation and services incorrectly coded. Ophthalmology services, such as ocular surgery, including the adnexa of the eye, integumentary repair and ophthalmological E/M, were not supported due to:

  • Documentation submitted does not adequately describe the service defined by the CPT code, HCPCS code and/or HCPCS modifier billed
  • Does not meet medical decision making key element for billed E/M service level
  • Missing a valid physician order as required by regulation, interpretive manual or LCD (includes physician signature or date)

 

Outpatient Therapy

CERT errors have been found specific to insufficient documentation and services incorrectly coded. Multiple therapy codes were not supported due to:

  • Documentation submitted does not adequately describe the service defined by the CPT code, HCPCS code and/or HCPCS modifier billed
  • Missing therapy progress notes to support billed therapy services
  • Missing therapy minutes 
  • Therapy initial evaluation with illegible identifier
  • Missing therapy initial evaluation from the Physician/Non-Physician Practitioner (NPP) taking care of the patient
  • Missing therapy certification/recertification by the Physician/NPP taking care of the patient
  • Missing or invalid medical doctor's orders for therapy
  • Missing or invalid plan of care

 

Podiatry

CERT errors have been found specific to insufficient documentation and service incorrectly coded. Multiple services such as E/M, therapy and surgery relevant to the skin and/or nails, were not supported due to:

  • Missing a valid physician order as required by regulation, interpretive manual or LCD (includes physician signature or date)
  • Though a valid ICD-9/ICD-10 code(s) was submitted, the ICD-9/ICD-10 code(s) alone was insufficient information
  • Documentation submitted does not adequately describe the service defined by the 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
  • Documentation meets higher level E/M service than what was billed
  • Missing therapy progress notes to support billed therapy services
  • Missing therapy plan of care

 

Radiology and Radiation Oncology

CERT errors have been found specific to insufficient documentation and service incorrectly coded. Multiple radiology and radiation oncology services were not supported due to:

  • Missing a valid physician order as required by regulation, interpretive manual or LCD (includes physician signature or date)
  • Though a valid ICD-9/ICD-10 code(s) was submitted, the ICD-9/ICD-10 code(s) alone was insufficient information
  • Missing diagnostic testing/laboratory results

 

Rheumatology

CERT errors have been found specific to insufficient documentation, medical necessity and service incorrectly coded. Certain services provided in the Rheumatology specialty, such as labs, E/M and injection codes, were not supported due to:

  • Missing a valid physician order as required by regulation, interpretive manual or LCD (includes physician signature or date)
  • Documentation submitted does not adequately describe the service defined by the CPT code, HCPCS code and/or HCPCS modifier billed

 

Surgery

CERT errors have been found specific to services incorrectly coded, medical necessity and insufficient documentation. Multiple surgery codes were not supported due to:

  • Missing a valid physician order as required by regulation, interpretive manual or LCD (includes physician signature or date)
  • Documentation submitted does not adequately describe the service defined by the CPT code, HCPCS code and/or HCPCS modifier billed
  • Missing a signature attestation statement for the illegibly signed medical record
  • Though a valid ICD-9/ICD-10 code(s) was submitted, the ICD-9/ICD-10 code(s) alone was insufficient information

 

Last Updated Jan 10, 2017