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Printed Date: 9/22/2015
The Comprehensive Error Rate Testing (CERT) program looks for improper payments on Medicare claims. Based on the 2020 annual report, here is the home health CERT information for Tennessee.
CERT Reviewer Error: 25 — Not Medically Necessary — Medical Necessity
There is no medical necessity for this home health episode: “beneficiary is stable; minimal risk of exacerbation of condition; no change in treatment; issues are chronic; HEP established some time ago. Home health services are not reasonable & necessary for this beneficiary open to home health for almost three years. Her primary diagnosis has been abnormal gait since the episode starting a year ago & she has been receiving both skilled nursing and physical therapy services since that time. Documented patient therapy goals are to increase functional strength, mobility and endurance. PT documents she lives alone, ambulates with a cane or a walker and is able to safely manage the equipment. She is able to tolerate 30 minutes of treatment. SN provides weekly visits for teaching on disease processes, long standing medications & energy conservation. She [beneficiary] complained of dizziness at times however this has been an ongoing problem and her physician is aware. Beneficiary has chronic, stable appearing conditions and there has been ample time to render teaching.”
Avoid Errors for Medically Unnecessary Service or Treatment
Submit all documentation related to the services rendered and billed to Medicare which supports the medical necessity of the services. Use the most appropriate diagnosis codes to identify the beneficiary’s medical diagnosis/diagnoses. Submit documentation to support the need for skilled care. Some reasons for services may include, but are not limited to, the following:
CERT Reviewer Error: 31 — Service Incorrectly Coded — Incorrect Coding
The billed HIPPS code is incorrectly coded. Documentation supports a change in HIPPS code for home health subsequent episode for billed DOS. Billed was 1BGKS which was adjusted per therapy threshold edit to 1BGMS. Provider had projected no rehab visits and had billed for seven (7) therapy visits. However, there are no orders to cover four (4) of these therapy visits.
Avoid Errors for Service Incorrectly Coded
To avoid down codes for this reason, the documentation should paint a consistent picture of the patient’s condition.
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Last Updated: 02/13/2020