North Carolina Part A CERT Information

The Comprehensive Error Rate Testing (CERT) program looks for improper payments on Medicare claims. Based on the 2018 annual report, here is the Part A CERT information for North Carolina:

  • Total claims reviewed: 854
  • Total dollars reviewed: $6,159,834.80
  • Total claims paid: 772
  • Total dollars paid: $5,317,926.93
  • Total claims denied: 82
  • Total dollars denied: $505,333.69
  • Claims with error code 16 — No Documentation Was Received: 1
  • Claims with error code 21 — Insufficient Documentation: 31
  • Claims with error code 25 — Medically Unnecessary Service or Treatment: 25
  • Claims with error code 31 — Service Incorrectly Coded: 1
  • Claims with error code 32 — DRG Change Due to Wrong Diagnosis Code or Principal Diagnosis Code: 8
  • Denied claims with error code 34 — Wrong Discharge Status Code: 19
  • Claims with error code 55 — MSP Error: 1

CERT Reviewer Error 16 — No Documentation Was Received
No medical records were received, only request letter cover sheet. The CERT process is a federally mandated program and non-submission of medical records results in a denial of all services. Compliance with the CERT process benefits the provider by ensuring the appropriate reimbursement of their claims, preventing unnecessary denials and appeals, and reflecting a positive impression on the provider industry by having a low payment error rate.

CERT Reviewer Error 21 — Insufficient Documentation
Hospital records are missing or inadequate. 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 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. Here are some tips to prevent this error:

  • 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

CERT Reviewer Error 26 — Invasive Procedure Not Medically Necessary (IPPS Only)
Billed service is not reasonable and necessary: The procedure code is removed from the coding sequence. The DRG code changed to reflect actual service billed. Per CERT, physician procedure code is not reasonable and necessary. The removal of these procedure codes is directly related to invasive procedure denial. Here are some tips to prevent this error:

  • Be sure the medical record documentation supports the services billed according to Medicare guidelines
  • History of patient
  • Progression of illness/disease
  • Recent changes

CERT Reviewer Error 31 — Services Incorrectly Coded
The billed HCPC incorrectly coded. Physician’s order or intent to order documentation for billed date of service. The documentation supports change in code from 85025 (Complete Blood Count w/ Automated Differential WBC) to 85027 (Complete Blood Count).

CERT Reviewer Error 32 — DRG Change Due to Wrong Diagnosis or Principal Diagnosis Code
The circumstances of inpatient admission always govern the selection of principal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” For reporting purposes, the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, or increased nursing care and/or monitoring.

Here are some tips to prevent this error:

  • The admitting diagnosis is not always the principle diagnosis
  • The condition may be determined after a workup or after surgery
  • All diagnosis that affect the current hospital stay are to be reported

CERT Reviewer Error 33 — DRG Change Due to Wrong Procedure Code
DRG Code changed to reflect actual service billed. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.

CERT Reviewer Error 34 — Wrong Discharge Status Code
Billed discharge status code is incorrect: Discharge disposition 06 – HH as coded by the facility. The discharge disposition should be 01 – Home. Per submitted documentation, beneficiary was discharged home.

CERT Reviewer Error 55 – MSP error
The review of CWF shows this beneficiary had No-Fault Insurance coverage in effect at the time of service. The MSP regulations require providers to pay Medicare within 60 days from the date a payment is received from another payer (primary to Medicare) for the same service for which Medicare paid.

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