Inpatient Rehab Facilities (IRFs) Common CERT Error Codes

The Comprehensive Error Rate Testing (CERT) program looks for improper payments on Medicare claims. In an effort to reduce CERT errors, Palmetto GBA is providing education to help you reduce the most common errors.

Based on the most recent 2018 annual report for Inpatient Rehabilitation Facilities, the common errors are Error codes 21 (Insufficient documentation) and 25 (Medically unnecessary service or treatment).

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, et al, or bone on bone process.

The documentation is insufficient to support services as billed.

Tips to Avoid Error 21

  • The medical necessity of the services must be documented and legible
  • Provide a complete history of pre-operative history and physical specifics
  • 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

CERT Reviewer Error 25 – Medically unnecessary service or treatment

The inpatient admission was not reasonable and necessary. Admitted due to lower extremity cellulitis; stable; no fever or leukocytosis. All services could have been provided as outpatient services.

Tips to Avoid Error 25

  • Be sure the medical record documentation supports the services billed according to Medicare guidelines
  • History of patient
  • Progression of illness/disease
  • Recent changes
  • Exacerbation of symptoms
  • Comorbidity
  • Secondary conditions
  • Labs

Last Updated: 10/26/2018