South Carolina Part A CERT Information

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

  • Total Claims reviewed: 375
  • Total Dollars reviewed: $2,893,484.37
  • Total Claims paid: 333
  • Total Dollars paid: $2,389,032.24
  • Total Claims denied: 42
  • Total Dollars Denied: $299,871.57
  • Claims with error code 21 — Insufficient Documentation: 16
  • Claims with error code 25 — Medically Unnecessary Service or Treatment: 14
  • Claims with error code 31 — Service Incorrectly Coded: 2
  • Claims with error code 32 — DRG Change Due to Wrong Diagnosis Code or Wrong Principal Diagnosis Code: 4
  • Claims with error code 33 — DRG Change Due to Wrong Procedure Code: 1
  • Denied claims with error code 34 — Wrong Discharge Status Code: 3
  • Claims with error code 99 — No medical records received after fourth request: 1

CERT Reviewer Error 21 — Insufficient documentation
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. 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. Admitted due to lower extremity cellulitis; stable; no fever or leukocytosis. All services could have been provided as outpatient services.

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 31 — Service Incorrectly Coded
The billed HCPC incorrectly coded. 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.

Here are some tips to prevent this error:

  • 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 of the 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

CERT Reviewer Error 32 — DRG Change Due to Wrong Diagnosis or Principal Diagnosis Code
Billed secondary diagnosis incorrectly coded. The DRG is changed from billed DRG 292 to DRG 291.

Billed principal diagnosis incorrectly coded. The DRG is changed from billed DRG 870 to DRG 207.

Billed secondary diagnosis incorrectly coded. The DRG is changed from billed DRG 056 to DRG 057.

Billed principal diagnosis incorrectly coded. The DRG is changed from billed DRG 193 to DRG 190.

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 62–Inpatient Rehab as coded by the facility. The discharge disposition should be 03–SNF. Per submitted documentation, beneficiary is to receive rehabilitation at SNF.

Billed discharge status code is incorrect: Discharge disposition 06–Home Health as coded by the facility. The discharge disposition should be 01–Home. The beneficiary began a home health episode outside of the three day window.

A tip to help prevent this error code is to identify the patient’s location at the conclusion of the encounter, if released or passed away in the facility.

CERT Reviewer Error 90 — Other Errors

CERT Reviewer Error 99 — No Response Received After Fourth Request for Medical Records
The claim was denied for provider non-response to four or more requests for medical records. 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. Compliance with the CERT process may also prevent additional medical review of providers and the provider industry.

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