The Comprehensive Error Rate Testing (CERT) program looks for improper payments on Medicare claims. Based on the 2018 annual report, here is the Part B CERT information for Alabama:

  • Total claims reviewed: 20
  • Total dollars reviewed: $2,946.65
  • Total claims paid: 6
  • Total dollars paid: $566.28
  • Total claims denied: 14
  • Total dollars denied: $2,380.37
  • Claims with error code 21 — Insufficient documentation: 14

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

Contact Palmetto GBA JJ Part B Medicare

Provider Contact Center: 877-567-7271

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