2020 West Virginia Comprehensive Error Rate Testing (CERT) Map

The Comprehensive Error Rate Testing (CERT) program looks for improper payments on Medicare claims. Based on the 2020 annual report, here is the Part A CERT information for West Virginia.

  • Total claims reviewed: 197
  • Total dollars reviewed: $1,248,892.55
  • Total claims paid: 188
  • Total dollars paid: $1,216,035.45
  • Total claims denied: 9
  • Total dollars denied: $47,910.00
  • Claims with error code 21 — Insufficient Documentation: 2
  • Claim with error code 25 — Medical Unnecessary Service or Treatment: 5
  • Claim with error code 31— Incorrect Coding: 2

CERT Reviewer Error: 21 — Insufficient Documentation
The documentation is insufficient to support services as billed.

For example, 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.

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
  • 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. 

For example, patient 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
  • Medical history of patient
  • Progression of illness/disease
  • Recent changes
  • Exacerbation of symptoms
  • Comorbidity
  • Secondary conditions
  • Labs

CERT Reviewer Error: 31 — Incorrect Coding
When a provider receives a Comprehensive Error Rate Testing (CERT) error for incorrect coding, it means the documentation submitted for review by the provider does not match the codes billed for the claim.

These codes may be ICD-CM, HCPCS, CPT or modifiers. Here are issues that lead to incorrect coding:

  • Incomplete notes
  • Care that was provided but not documented
  • Missing test results
  • Post-operative complications not documented
  • Documentation not completed timely
  • Illegible documentation
  • Inconsistent documentation

Tips to Avoid Error 31

  • Make sure the date(s) of service are documented
  • Ensure the proper principle diagnosis and principle procedure is coded correctly
  • Include all documentation to support the codes billed
  • Use a checklist to ensure all essential pieces are included in the record Make sure that both sides of double-sided documents are submitted
  • Remember it is the billing provider’s responsibility to obtain any necessary information required for the record review, regardless of the location of the documentation

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