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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 most recent 2018 report, here is the Part A CERT information for Virginia/West Virginia:
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 preoperative 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:
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:
CERT Reviewer Error 32 — DRG Change Due to Wrong Diagnosis or Principal Diagnosis Code
Billed principal diagnosis incorrectly coded: The DRG is changed from the billed DRG 281 to DRG 287. Per submitted documentation, discharge summary noted a final discharge diagnosis that supports this change.
Billed principal diagnosis incorrectly coded: Principal diagnosis code is removed from the coding sequence. The DRG is changed from the billed DRG 178 to DRG 392.
Billed principal diagnosis incorrectly coded: The DRG is changed from the billed DRG 281 to DRG 871. Per submitted documentation, discharge summary noted a final discharge diagnosis that supports this change.
CERT Reviewer Error 34 — Wrong Discharge Status Code
Billed discharge status code is incorrect: Discharge disposition 01 – Home as coded by the facility. The discharge disposition should be 06 – HH. Per submitted documentation, beneficiary was discharged with home health services, this was confirmed.
Billed discharge status code is incorrect: Discharge disposition 06 – HH as coded by the facility. The discharge disposition should be 01 – Home. CWF does not support home health status.
CERT Reviewer Error 90 — Other Errors
Any error not covered by an existing code is counted in this category. The HIPPS/RUG MDS for the billed date of service (s) is not in the repository.
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Last Updated: 03/04/2019