Do You Know What Your Comprehensive Error Rate Testing (CERT) Contractor Is Looking For?

Published 01/21/2022

Do You Know What Your Comprehensive Error Rate Testing (CERT) Contractor Is Looking For?

Are you using the correct procedure code(s)?
Procedure codes are not supported in the documentation for inpatient admission with recoding of services.

Example: Billed secondary diagnosis incorrectly coded. Remove secondary diagnosis J18.9 (pneumonia, unspecified organism). The DRG is changed from billed DRG 480 to DRG 481. ICD-10-CM Official Guidelines for Coding and Reporting, Section III, Reporting Additional Diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS), item 11-b as “all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or length of stay.” Could not locate physician documentation to support a diagnosis of pneumonia. Possible pneumonia was documented on the radiology reports, however could not find physician documentation to clarify this diagnosis.

Example: Remove procedure code 0F9400Z, (Drainage of Gallbladder with Drainage Device, Open Approach). The DRG is changed from billed DRG 410 to DRG 416. Per ICD-10-PCS Official Guidelines for Coding and Reporting, procedure code b is not appropriate. Per guideline B6.1b: "Materials such as sutures, ligatures, radiological markers and temporary post-operative wound drains are considered integral to the performance of a procedure and are not coded as devices." Per submitted documentation, a JP drain was left in place, which is integral to the procedure performed based on the above coding guideline.

Example: Procedure code 02RF38Z, (Replacement of Aortic Valve with Zooplastic Tissue, Percutaneous Approach) is removed from the coding sequence. The DRG is changed from billed DRG 267 to DRG 307. The submitted medical record has insufficient documentation to support TAVR coverage criteria. Missing documentation of an independent cardiothoracic surgeon and an interventional cardiologist pre-operative face-to-face evaluation to support the TAVR billed. Refer to the National Coverage Determination (NCD) for Trans-catheter Aortic Valve Replacement (TAVR) (20.32).

Example: Procedure codes 0JH608Z (insertion of cardio defibrillator into chest, open approach) and 0JH60PZ (insertion of cardiac rhythm device, open approach) are removed from the coding sequence. The DRG is changed from billed DRG 245 to DRG 291. The submitted medical record is missing a formal, evidence-based, shared decision-making tool encounter between the patient and the physician prior to initial ICD implantation (as defined in Section 1861(r)(1)) or qualified nonphysician practitioner (meaning a physician assistant, nurse practitioner, or clinical nurse specialist as defined in §1861(aa)(5)). The shared decision-making encounter may have occurred at a separate visit prior to admission. Refer to the National Coverage Determination (NCD) for Implantable Automatic Defibrillators (20.4).

How to Avoid Denials Using Incorrect Procedure Codes

  • Verify that you are using the correct code for the procedure and diagnosis
  • Verify the beneficiary information
  • Be careful with undercoding and upcoding (payment errors are issued for incorrectly billing a lower level of payment, the same as billing a higher level of payment)
  • Make sure documents are signed, dated and authenticated (treatment plans, evaluations, notes and orders)
  • If the signature is missing (except in the case physicians’ orders), send a completed signature attestation. If the signature is illegible, you may also send a signature log.
  • Review the National Coverage Determinations (NCDs) associated with procedure codes to ensure the documentation to support the procedure is submitted
  • Stay current with coding changes
  • Be diligent, communicate and follow through
  • Provide documentation to support the procedure code(s)

Insufficient Documentation

Example: Missing a signed/authenticated psychiatric evaluation by Dr. Smith, an authenticated initial certification by the physician, and authenticated psychiatric progress notes. Received the Psychiatric evaluation to include treatment plan by Dr. Smith, but not authenticated.

Example: Procedure code 0RRJ00Z, (Replacement of Right Shoulder Joint with Reverse Ball and Socket Synthetic Substitute, Open Approach) and 0RPJ0JZ (Removal of Synthetic Substitute from Right Shoulder Joint, Open Approach) are removed from the coding sequence. The DRG is changed from billed DRG 483 to DRG 561. There is insufficient documentation to support the procedure. The submitted medical record does not include an authenticated operative report.
Provide sufficient documentation to support services billed to include and not limited to:

  • History and physical
  • Pre- and post-operative notes, if applicable
  • Physician’s orders
  • Physician’s notes
  • Psychiatric progress notes and evaluation
  • Initial certifications and recertification statements
  • Diagnostic studies and labs
  • Discharge summary
  • Make sure documents are signed, dated and authenticated (treatment plans, evaluations, notes, and orders)
  • If the signature is missing (except in the case physician orders), send a completed signature attestation. If the signature is illegible, you may also send a signature log.

Not Meeting Medical Necessity

Example: IRF admission not reasonable and necessary: not in need of the intensive therapy services of an IRF: on admission the beneficiary was min assist in all areas; her medical needs were minimal. In addition, there was no supervision by a rehab physician, or one with specialized training and experience in inpatient rehab. Also, the visits with the beneficiary were mostly provided by NP or PA.

Example: IRF admission not reasonable and necessary: Documentation does not support that the beneficiary had complex nursing, medical management and intensive rehabilitative therapy needs post-discharge from the acute facility that required an interdisciplinary approach to the delivery of rehab care

Example: Insufficient documentation to support IRF admission due to missing the PT/OT/SLP therapy documentation of participation in the team conferences.
Submit the following and not limited to:

  • History and physical/ Post Admit Physician Evaluation (PAPE)
  • Pre- and post-operative notes if applicable
  • Physician’s orders/progress notes
  • Physician’s notes
  • Documentation of supervision by a rehabilitation physician or one with specialized training and experience in inpatient rehab
  • Therapy evaluations, treatment notes and discharge notes
  • Nursing Notes
  • Interdisciplinary Team Conferences
  • Individualized plan of care
  • Preadmission Screening (PAS)
  • IRF-PAI
  • Diagnostic tests and labs
  • Make sure documents are signed, dated and authenticated (treatment plans, evaluations, notes, and orders)
  • If the signature is missing (except in the case physician orders), send a completed signature attestation. If the signature is illegible, you may also send a signature log

Are you using the correct discharge status code?

Example: Disagree with discharge disposition 03-SNF as coded by the facility. The discharge disposition should be 01-Home. (D/C disposition checked in CWF.)
Verify where the beneficiary is going after discharge. Documentation should reflect what location the patient will be going to after discharge. Providers are encouraged to follow-up with the patient after discharge and prior to submitting the claim to ensure that the patient went to the planned facility. This will prevent incorrect billing and unnecessary adjustments to the claim if incorrectly coded

Below are some common discharge codes that are used:

  • 01 — Discharge to home or self-care
  • 02 — Discharged or transferred to a ST General hospital for inpatient care
  • 03 — Discharged or transferred to a SNF
  • 04 — Discharged or transferred to an intermediate care facility
  • 06 — Discharged home with HH services
  • 07 — Left AMA
  • 09 — Admitted as an inpatient to this hospital
  • 20 — Expired

Resources