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 Tennessee:

  • Total claims reviewed: 107
  • Total dollars reviewed: $492,452.92
  • Total claims paid: 99
  • Total dollars paid: $ 477,958.78
  • Total claims denied: 8
  • Total dollars denied: $14,494.14
  • Claims with error code 21 — Insufficient documentation: 4
  • Claims with error code 31— Services incorrectly coded
  • Claims with error code 35 — Not covered or unallowable service: 1
  • Claims with error code 99 — No response received after 15 days from the 4th request for medical records: 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 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: 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.

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Provider Contact Center: 877-567-7271

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