Medicare Part A Payments for End-Stage Renal Disease Dialysis Services and Comprehensive Error Rate Testing (CERT)

Published 08/13/2019

Part A Outpatient Dialysis services with a bill type of 72X have historically been in the top 10 types of services in error per the November 2017 and 2018 CERT reporting periods. For Jurisdiction M, the November 2019 CERT report period has ESRD claims ranked #7 for top services in error and all errors are related to the billing provider submitting insufficient documentation. For Jurisdiction J, the November 2019 CERT report period has ESRD claims ranked #3 for top services in error and are also related to the billing provider submitting insufficient documentation. 

CERT Error Code 21 — Examples of CERT Errors for Insufficient Documentation

  • Missing Authenticated hemodialysis standing orders for the billing period (standing orders outdated) 
  • Missing Authenticated Physician signed and dated orders for the home dialysis procedure
  • Missing daily CAPD/CCPD treatment notes or patient CAPD/CCPD treatment summary
  • Missing Interdisciplinary CAPD treatment plan
  • Missing Physician/NP's monthly progress notes
  • Missing Physician attestation for unsigned dialysis treatment notes

When a provider receives a Comprehensive Error Rate Testing (CERT) error for no documentation or insufficient documentation, it means that elements of the medical record that are imperative for Medicare payment were not sent in to the CERT contractor for review. Here are some tips to prevent this error:

  • Submit signed (with credentials) and dated orders to cover dates of service billed
    • If the signed and dated orders are illegible, obtain a signature log
    • If using standing orders, make sure they are up-to-date
    • If electronic orders, include policy and procedure related to using electronic signatures
  • Submit signed (with credentials) and dated progress or treatment notes that show the medical necessity for ESRD to cover the dates of service billed
    • If progress/treatments notes are not signed, obtain an attestation from the physician
    • Include progress/treatment notes on and prior to the date of service to ensure documentation reflects medical necessity for ESRD treatment
  • Include all documentation to support the codes billed
  • Use a checklist to ensure all of the essential pieces are included in the record
  • Make sure that both sides of double-sided documents are submitted
  • Review ESRD Billing and ESRD Payment for more information
  • Remember it is the billing provider’s responsibility to obtain any necessary information required for the record review, regardless of the location of the documentation

Providers have 120 days to appeal from date of demand letter and also have the option to submit the missing documentation to CERT with the barcoded coversheet request. Please keep in mind that the appeals time line is ongoing regardless of sending in the documentation to CERT for re-review. The benefit to submitting the documentation directly to CERT is the potential to have the error removed entirely.

Appeals must be requested within 120 days of request for funds regardless if the documentation was sent to CERT or not. 

References include but are not limited to: