Virginia/West Virginia 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 Virginia/West Virginia:

  • Total Claims reviewed: 830
  • Total Dollars reviewed: $5,826,344.97
  • Total Claims paid: 523
  • Total Dollars paid: $5,144,575.19
  • Total Claims denied: 89
  • Total Dollars Denied: $828,196.64
  • Claims with error code 16 — No Documentation Was Received: 2
  • Claims with error code 21 — Insufficient Documentation: 32
  • Claims with error code 25 — Medically Unnecessary Service or Treatment: 25
  • Claims with error code 26 — Invasive Procedure Not Medically Necessary: 2
  • Claims with error code 31 — Service Incorrectly Coded: 2
  • Claims with error code 32 — DRG change due to Wrong Diagnosis Code or Principal Diagnosis Code: 8
  • Claims with error code 33 — DRG Change Due to Wrong Procedure Code: 5
  • Denied claims with error code 34 — Wrong Discharge Status Code: 4
  • Claims with error code 41 — Services Billed Were Not Rendered
  • Claims with error code 60 — Unbundling
  • Claims with error code 90 — Other Errors: 2

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:

  • 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 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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