Error Descriptions - JF Part A
CERT Error Descriptions
|No documentation due to extenuating circumstances
|Response received - improper documentation -No documentation was received, or no documentation related to the claim line under review was received from the provider, after full process was pursued and exhausted, and there is no evidence to support another error code. The documentation of all services rendered is absolutely necessary in order for a claim to be properly evaluated. The medical records should be complete and legible. If there is no documentation, then there is no justification for the services or the level of care billed. If there is insufficient documentation on claims that have already been adjudicated by Medicare, the reimbursement made may be considered an overpayment and the funds can be recovered.
|Insufficient documentation - The provider submitted some documentation, but it is inconclusive to support the billed service. Based on the medical records provided the reviewer could not conclude that some of the allowed services were actually provided at level billed, and/or medically necessary. The documentation of all services rendered is absolutely necessary in order for a claim to be properly evaluated. The medical records should be complete and legible. If there is no documentation, then there is no justification for the services or the level of care billed. If there is insufficient documentation on claims that have already been adjudicated by Medicare, the reimbursement made may be considered an overpayment and the funds can be recovered.
|Medically unnecessary service or treatment -There is sufficient documentation in the records for the reviewer to make an informed decision that the medical services or products were not medically necessary. There is affirmative evidence that shows there was an improper diagnosis or deficient treatment plan, reasonably connected to the provision of unnecessary medical services or treatment for an illness/injury not applicable to improving a patient's condition.
|Invasive Procedure Not Medically Necessary (Inpatient PPS Only)
|Service incorrectly coded -The reviewer determines and documents that the medical service, treatment and/or equipment was medically necessary and that such service, treatment and/or equipment was provided at a proper level of care, but billed and paid based on a code that was not accurately reflected in the documentation provided. Coding of services was identified as a billing error. The coding policy manuals, developed by The American Medical Association Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS), are listings of descriptive terms and identifying codes for reporting medical services and procedures. There must be sufficient documentation to verify the services were performed and correctly coded. It is your responsibility as a provider to select the name of the service that most accurately identifies the service and the correct number of units per the CPT® or HCPCS description and medical documentation. Failure to correct code procedures and services accurately results in the correct coding of the procedures based upon the documentation received to enable payment accurately.
|DRG, wrong diagnosis code
|DRG, wrong procedure code
|Wrong discharge status code
|Not covered or unallowable service - Neither the question of medical necessity nor the questions of whether the medical service, treatment, or equipment was actually provided are elements of this error code. A determination of medical necessity is not to be conducted for this error code as errors of this type include non-covered or unallowable services that were billed to and paid as covered by Medicare where there is a CMS regulation, policy or general law that prohibits Medicare coverage.
|Service provided by someone other than the billing provider - The medical service, treatment or equipment must be documented as medically necessary. It was billed as being rendered by a medical provider or entity that is eligible to receive Medicare payment, but was actually rendered by a provider or entity other than the billing provider or entity.
|Services billed were not rendered - The reviewer concluded, based on actual evidence in the records, that the services the provider billed and the contractor paid were either not performed, or products were not provided.
|Duplicate payment -The reviewer concluded, based on actual evidence in the records, that the services the provider billed and the contractor paid were either not performed, or products were not provided.
|DRG window error
|MSP error -Medicare made payment for a service that should have been paid by another entity such as a private insurer.
|Unbundling -Reviewer concluded that medical services were provided and billed as separate services, usually at a higher cumulative rate, when a CMS regulation or policy, or local practice dictates that they should have been billed as a set, rather than individual services.
|Utilization - Reviewer concluded that medical services provided were delivered in an inappropriate facility, thereby raising the costs associated with the delivery of the services, which have been ascertained by the reviewer to be medically necessary and allowable. This may include a situation where non-emergency services are provided in an emergency room setting, usually at higher cost.
|Invalid inpatient admission
|Other compliance errors -Includes all compliance related errors. No error should be included in this category where it has been counted in another category.
|Ineligible beneficiary -The reviewer concluded the beneficiary was not eligible to receive Medicare benefits at the time services were provided for which Medicare coverage was sought.
|Ineligible provider -This provider was not eligible to participate in the Medicare program during the period that billable services were submitted for payment under Medicare, or the provider was not eligible to provide a specific service that was billed.
|Other errors -Any error not covered by an existing code should be counted in this category. No compliance errors should be included here.
|Span date error
|No response received after 90 days from initial request for medical records
CERT Subcategory Error Descriptions
|Provider indicates no such patient exists.
|Provider indicates that although this patient exists, no such service was provided to the patient
|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.
|Provider indicates that another department within the provider is responsible for fulfilling documentation requests.
|Provider indicates that a different provider – a third party – has the relevant medical record.
|Provider indicates they have the medical record but refuse to provide it without payment for copying/mailing charges.
|Provider indicates they have the medical record but refuse to provide it for some other reason.
|Extenuating Circumstances (fire, flood, explosion, etc.).
|Provider number has been deactivated.
|Provider has gone out of business.
|No comment by provider.
|Nursing home or custodial care records.
|Results of diagnostic or laboratory test.
|A valid physician order as required by regulation, interpretive manual, or LMRP (includes physician signature or date).
|Documentation did not include DOS or name of beneficiary (or legible identity of performing provider before 04/27/10).
|Though a valid ICD-9 code(s) was submitted, the ICD-9 code(s) alone was insufficient information.
|Documentation submitted does not adequately describe the service defined by the CPT code, HCPCS code, a HCPCS modifier billed.
|Valid CMN (including physician signature and date).
|Therapy records (PT, OT, ST).
|Records for the wrong DOS were submitted.
|Valid Plan of Care (including physician signature and date).
|Service not rendered.
|History does not meet level required.
|Evaluation and Management does not meet level required.
|Exam does not meet the level required.
|Medical Decision Making does not meet the level required.
|Service billed as an annual exam and not covered.
|Service requires 2/3 levels and only 1 key component was provided.
|Service does not meet definition of critical care.
|Service does not meet definition of a new patient.
|Service provided or documentation provided exceeds the needs of the beneficiary.
|Documentation is illegible and service is denied or down code (i.e. Medical Decision Making and exam but no History).
|R/N met, fails signature ONLY.