End-Stage Renal Disease Dialysis Services and Comprehensive Error Rate Testing (CERT)

Part A Outpatient Dialysis services with a bill type of 72X have historically been in the top 10 types of services in error for Comprehensive Error Rate Testing (CERT) reporting periods. 

When a provider receives a 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 into the CERT contractor for review.

The most common reason for errors received are related to the billing provider submitting insufficient documentation. Below are some Examples of missing documentation that could result in your claim denying are below.

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

• Authenticated hemodialysis standing orders for the billing period (standing orders outdated) 
• Authenticated Physician signed and dated orders for the home dialysis procedure
• Daily CAPD/CCPD treatment notes or patient CAPD/CCPD treatment summary
• Documentation supporting performance of the CCPD training such as a training log or nurse’s progress note
• Interdisciplinary CAPD treatment plan
• Physician/NP's monthly signed progress notes
• Physician attestation for unsigned dialysis treatment notes
• Missing dialysis treatment records for each visit
• Signed Order or Protocol orders in a medical record

Tips to Prevent Errors

• 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 for dates of service to support the codes billed
• Use a checklist to ensure all the essential pieces are included in the record
• Make sure that both sides of double-sided documents are submitted
• 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 or you have the option to submit the missing documentation to CERT with the barcoded coversheet request. Please keep in mind that the appeals timeline 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 of if the documentation was sent to CERT or not. 

References Include (But Are Not Limited to)

• CERT C3Hub 
• CMS Internet Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 11 (PDF), Section 50.A — ESRD PPS Base Rate; Per Treatment Unit of Payment (PDF)  
• CMS Internet Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 6 (PDF), Section 20.5.2 — Coverage of Outpatient Therapeutic Services Incident to a Physician's Service  
• CMS Internet Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 8 (Outpatient ESRD) (PDF), Section 10 (General Description of ESRD Payment and Consolidated Billing Requirements) and, Section 50.6.2 (Payment for Hemodialysis Sessions)  
• CMS Internet Only Manual (IOM) Publication 100-08, Medicare Program Integrity Manual, Chapter 3 (PDF), Section 3.3.2.4 (Signature Requirements — Orders) and, Section 3.3.2.4.C — Signature Attestation Statement   
• CMS MLN Matters Article 909160 (PDF) Complying with Medical Record Documentation Requirements