CERT Error Descriptions

Code Description
15 No documentation due to extenuating circumstances
16 Response received - improper documentation
21 Insufficient documentation
25 Medically unnecessary service or treatment
31 Service incorrectly coded
34 Wrong discharge status code
35 Not covered or unallowable service
40 Service provided by someone other than the billing provider
41 Services billed were not rendered
45 Duplicate payment
55 MSP error
60 Unbundling
65 Utilization
66 Invalid inpatient admission
80 Other compliance errors
81 Ineligible beneficiary
82 Ineligible provider
90 Other errors
98 Span date error
99 No response received after 15 days from 4th request for medical records (OIG letter)

 

CERT Subcategory Error Descriptions

16 - Response received - improper documentation

Code Description
11 Provider indicates no such patient exists
12 Provider indicates that although this patient exists, no such service was provided to the patient
13 Provider indicates that they do not have a medical record for that date of service but they do have a medical record for that service just a few days before or after the service in question. The claim in question is a duplicate claim
14 Provider indicates that another department within the provider is responsible for fulfilling documentation requests.
15 Provider indicates that a different provider - a third party - has the relevant medical record
16 Provider indicates they have the medical record but refuse to provide it without payment for copying/mailing charges
17 Provider indicates they have the medical record but refuse to provide it for some other reason
18 Extenuating Circumstances (fire, flood, explosion, etc.)
19 Provider number has been deactivated
20 Provider has gone out of business
21 No comment by provider

 

21 - Insufficient documentation

Code Description
22 Hospital record
23 Nursing home or custodial care records
24 Results of diagnostic or laboratory test
25 A valid physician order as required by regulation, interpretive manual, or LMRP (includes physician signature or date)
26 Documentation did not include DOS, name of beneficiary, or legible identity of performing provider
27 Though a valid ICD-9 code(s) was submitted, the ICD-9 code(s) alone was insufficient information
28 Documentation submitted does not adequately describe the service defined by the CPT code, HCPCS code, or HCPCS modifier billed
32 Therapy records (PT, OT, ST)
33 Records for the wrong DOS were submitted
34 Valid Plan of Care (including physician signature and date)
35 Other
47 R/N met, fails signature ONLY
48 Illegible identifier
49 No signature

 

31 - Service incorrectly coded

Code Description
36 Service not rendered
37 History does not meet level required
38 Evaluation and Management does not meet level required
39 Exam does not meet the level required
40 Medical Decision Making does not meet the level required
41 Service billed as an annual exam and not covered
42 Service requires 2/3 levels and only 1 key component was provided
43 Service does not meet definition of critical care
44 Service does not meet definition of a new patient
45 Service provided or documentation provided exceeds the needs of the beneficiary
46 Documentation is illegible and service is denied or down coded (i.e. Medical Decision Making and exam, but no History)

 

Last Updated Oct 16, 2017