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 Alabama:

  • Total claims reviewed: 524
  • Total dollars reviewed: $3,876,831.95
  • Total claims paid: 422
  • Total dollars paid: $ 2,505,028.81
  • Total claims denied: 101
  • Total dollars denied: $1,380,499.12
  • Claims with error code 16 — No documentation was received: 1
  • Claims with error code 21 — Insufficient documentation: 10
  • Claims with error code 25 — Medically unnecessary service or treatment: 18
  • Claims with error code 26 — Invasive Procedure Not Medically Necessary: 1
  • Claims with error code 32 — DRG change due to wrong diagnosis code or principal diagnosis code: 1
  • Claims with error code 33 — DRG change due to wrong procedure code: 1
  • Denied claims with error code 34 — Wrong Discharge Status Code: 10
  • Claims with error code 90 — Other errors: 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
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: 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 is changed from billed DRG 267 to DRG 253. Per CERT Physician procedure code is not reasonable and necessary. The removal of these procedure codes is directly related to invasive procedure denial.

CERT Reviewer Error: 32 — DRG Change Due to Wrong Diagnosis or Principal Diagnosis Code
Billed principal diagnosis incorrectly coded: Principal diagnosis code is removed from the coding sequence. The DRG is changed from the billed DRG 064 to DRG 098.

CERT Reviewer Error: 33 — Proper Coding Is Necessary on Medicare Claims Because Codes Are Generally Used in Determining Coverage and Payment Amounts.
The Centers for Medicare & Medicaid Services understands that physicians may not always provide suppliers of DMEPOS with the most specific diagnosis code, and may provide only a narrative description. In those cases suppliers may choose to utilize a variety of sources to determine the most specific diagnosis code to include on the individual line items of the claim. These sources may include, but are not limited to: coding books and resources, contact with physicians or other health professionals, documentation contained in the patient’s medical record, or verbally from the patient’s physician or other healthcare professional.

On inpatient claims providers must report the principal diagnosis. The principal diagnosis is the condition established after study to be chiefly responsible for the admission.

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: 90 — Other Errors
Any error not covered by an existing code is counted in this category. You can include an example of the error specific to this error code (just example, but this is another error code).Documentation to support the XXX claims billed were denied for NOTMN (not medically necessary). Clinical documentation from the treating physician of record does not support the performance of the billed services for DOSXXXX. The medical documentation submitted is not signed and/or the signature is not clearly legible. There is no attestation statement or signature log. The documentation submitted does not contain physician orders, progress notes, relevant laboratory results, relevant scans / X-ray reports, etc., and any other documentation necessary to support the medical necessity of the services rendered.

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Provider Contact Center: 877-567-7271

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