By: Matthew Fischer
In CMS’ latest “MLN Connects” newsletter, the agency discusses the Comprehensive Error Rate Testing (CERT) program and the top five documentation errors committed by providers. Providers should pay close attention when CMS releases these types of notices. If selected for CERT review, providers are subject to potential action such as post-payment denials, payment adjustments, or other actions depending on the results of the review. Therefore, providers should ensure they fully understand Medicare’s documentation requirements and how to meet these demands.
The newsletter includes a link to a new video posted on YouTube. In the video, the CMS representative identifies the following top five errors.
Documentation Error #1
First up is insufficient documentation. By insufficient documentation, they mean that the medical documentation is inadequate or a specific component required as a condition for payment is missing. An example is a missing signature or date.
Documentation Error #2
Second, medical necessity was the next top error. In this situation, there is sufficient documentation; however, based on Medicare coverage policy, the requirements for coverage are not met. A good example relates to the prescription of durable medical equipment (DME). Most DME are not covered unless the patient suffers from a specific diagnosis. If the physician note does not contain evidence of a required diagnosis, the claim will be denied for lack of medical necessity.
Documentation Error #3
The next top error is incorrect coding. By incorrect coding, this means documentation was submitted that supports a different code than what was billed, the service was unbundled, or the service was performed by a provider other than the billing provider.
Documentation Error #4
The fourth top error is labeled by CMS as “other.” CMS states other includes duplicate payment errors and unallowable services.
Documentation Error #5
Finally, the fifth top error is the failure to submit documentation. It’s hard to believe but some providers fail to respond to repeated requests for medical records.
What is the CERT program? This program was implemented by CMS to identify improper payments in the Medicare program. To accomplish this, a random sample of Medicare claims are reviewed (i.e. for coverage, coding, and billing compliance) to determine if the claims were appropriately paid or denied. If a claim is selected, the provider will receive a medical record request from a contractor. This authority is addressed in Chapter 3 of the Medicare Program Integrity Manual. Who are the players? The program is managed by two contractors, a statistical contractor and review contractor also known as the CERT SC and CERT RC.
The documentation process is arguably as important as interactions with patients. When providers take accurate and detailed notes, not only is a better continuity of care provided but the chance of being denied by a CERT review is decreased. Simple interventions can greatly improve clinical documentation. For providers that are unsure whether their documentation falls short, an experienced Medicare attorney should be consulted for an analysis.
