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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 2018 annual report, here is the Part A CERT information for Tennessee:
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:
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: 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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Last Updated: 03/04/2019