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 Georgia:

  • Total claims reviewed: 18
  • Total dollars reviewed: $2,399.85
  • Total claims paid: 11
  • Total dollars paid: $1,637.61
  • Total claims denied: 7
  • Total dollars denied: $762.24
  • Claims with error code 21 — Insufficient documentation: 6
  • Claim with error code 31 — Incorrect Coding: 1

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 Error Code 31 — Incorrect Coding
The 31 error code means the documentation submitted for review by the provider does not match the codes billed for the claim. To prevent this error, make sure this documentation is submitted in the record for review.

  • Make sure the date(s) of service are documented
  • Ensure the proper principle diagnosis and principle procedure is coded correctly
  • Include all documentation to support the codes billed
  • Use a checklist to ensure all of the essential pieces are included in the record
  • Make sure that both sides of double sided documents are submitted
  • Remember it is the billing provider’s responsibility to obtain any necessary information required for the record review, regardless of the location of the documentation

Contact Palmetto GBA JJ Part B Medicare

Provider Contact Center: 877-567-7271

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