In the May 2006 Comprehensive Error Rate Testing (CERT) report, the CERT contractor, AdvanceMed, reported a 7.8% paid claims error rate BETOS (Berenson Eggers type of Service) category PC6, Minor procedures, other, for all carriers in the nation. CERT projected the national dollars paid incorrectly amount to be $246,490,860.00.
The latest data available for South Carolina comes from the November 2005 report with an error rate of 11.1%, which is significantly higher than the national error rate.
Despite the fact that the BETOS group contains more than 350 procedure codes, only seven procedure codes were found to be in error. Six out of the seven codes were for physical therapy services. Several errors were noted on CPT © code 97110, therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. Other procedure codes with errors were 97140 (manual therapy techniques), 97035 (ultrasound, each 15 minutes), 97150 (therapeutic procedure(s), group), 97022 (whirlpool) and 97116 (gait training).
According to AdvanceMed, the most commonly sighted reason for denial of the above codes was for lack of a written plan of care for physical therapy services. The referring/attending physician must sign the plan of care. Multiple claims were noted to be missing the physician's order for the date of service billed, as well as an initial evaluation and re-evaluation.
All documentation to support services billed should be sent to AdvanceMed or the CERT documentation contractor
immediately upon request to avoid an overpayment. If the documentation requested by AdvanceMed is not readily available in your facility, it is the billing provider's responsibility to obtain the required records and provide them for review. We suggest that you designate one person in your office to handle all requests from AdvanceMed.
Additional information about the CERT program can be found at
www.cms.gov/cert.