Comprehensive Error Rate Testing (CERT) Error: Medical Necessity Not Met for Hospice Providers

Published 04/13/2018

When a hospice provider receives a Comprehensive Error Rate Testing (CERT) error for 'Medical Necessity Not Met', it means the documentation submitted for review by the provider does not meet the coverage guidelines for the Hospice Medicare Benefit. To prevent this error, make sure the following information is submitted in the record for review:

  1. Hospice election information
    • Identification of the particular hospice that will provide care to the individual
    • The individual’s or representative’s (as applicable) acknowledgment that the individual has been given a full understanding of hospice care, particularly the palliative rather than curative nature of treatment
    • The individual’s or representative’s (as applicable) acknowledgment that the individual understands that certain Medicare services are waived by the election
    • The effective date of the election
    • The signature of the individual or representative
  2. Comprehensive assessment
  3. Physician Certification
    • Signed and dated
    • Reference to the benefit period
    • Verbal certification included if applicable
    • Documentation that medical director is the attending is applicable
  4. Narrative/face to face encounter narrative
    • Documentation of clinical findings
    • Attestation
  5. Documentation to support terminal prognosis (examples may include)
    • History
    • Progression of illness/disease
    • Recent changes
    • Exacerbation of symptoms
    • Comorbities
    • Secondary conditions
    • Variables that are measureable
    • Labs
    • Palliative Performance Scale (PPS)/Karnofsky scale
    • FAST scale for Alzheimer’s patients
    • Weight loss
    • Body Mass Index (BMI)
    • Percentage of meals eaten
    • Vital signs
    • Interdisciplinary Group (IDG) meeting notes
    • Medication changes
    • Skin integrity
    • Recurrent Aspiration
    • Infections
  6. Plan of care (POC)
    • Updated every 15 days
  7. Appropriate continuous care documentation, if applicable:
    • Documentation of the crisis 
    • Minimum of eight hours during
    • Nursing care must be provided for more than half of the period of care
    • Documentation of care provided
  8. Appropriate general inpatient care (GIP) documentation, if applicable:
    • Medication adjustments/treatments
    • Documentation describing why care could not be performed in the home setting
    • Sudden deterioration requiring intensive nursing intervention
    • Uncontrolled nausea and vomiting
    • Pathologic fractures
    • Respiratory distress which becomes unmanageable
    • Open lesions requiring frequent skilled care
    • Traction and frequent repositioning requiring more than one staff member
    • Complex wound care requiring complex dressing changes
    • Severe agitated delirium or acute anxiety or depression secondary to the end-stage disease process requiring extensive intervention

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