2020 Jurisdiction J Part B Georgia Comprehensive Error Rate Testing (CERT)

The Comprehensive Error Rate Testing (CERT) program looks for improper payments on Medicare claims. Based on the 2020 annual report, here is the Jurisdiction J Part B CERT information for Georgia.

• Total claims reviewed: 19
• Total dollars reviewed: $2,654.58
• Total claims paid: 18
• Total dollars paid: $2,508.51
• Total claims denied: 1
• Total dollars denied: $146.07
• Claims with error code 21 — Insufficient documentation: 1

CERT Reviewer Error: 21 — Insufficient Documentation
Missing the following documentation: Pre-Operative History and Physical specifics as related to bilateral knees prior to surgery such as conservative treatment completed, injections, physical therapy; pain medications and pre-operative X-rays showing specific osteoarthritic changes such as joint space narrowing, osteophytes, sclerosis, etc., or bone-on-bone process. The documentation is insufficient to support services as billed.

Tips to Prevent this Error

• The medical necessity of the services must be documented and legible
• Provide a complete history of pre-operative history and physical history of illness from onset to decision for surgery
• Prior courses of treatment and results
• Any recent injections
• Document any physical therapy provided prior to surgery
• Include pain medications provided
• Include any X-rays showing changes in condition
• Obtain any documentation needed from a third party such as a nursing home, lab facility, etc.
• Current symptoms and functional limitations
• Results of any special tests

References

• Medicare Program Integrity Manual — Chapter 3 (PDF, 594 KB)
• Palmetto GBA Article: CERT Error: Insufficient Documentation
• E/M guidelines, CPT 2018 and PUB 100-04, Chapter 12 § 30.6.1 (PDF, 1.12 MB) (Selection of Level of Evaluation and Management Service)

Insufficient Documentation Example
Physician's order for or documentation of physician intent to order the Urine Culture and Susceptibility Studies done on DOS XXXX and clinical documentation supporting the medical necessity of the Urine Culture and Susceptibility Studies were not provided.