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COMMON MEDICAL RECORDS ERRORS

What Is the CERT Program? 

The CMS implemented the CERT program to measure improper payments in the Medicare FFS program. CERT selects a stratified random sample of approximately 50,000 claims submitted to Part A/B MACs and DME MACs during each reporting period. This sample size allows CMS to calculate a national improper payment rate and contractor and service-specific improper payment rates. 

It is important to note that the improper payment rate is not a “fraud rate”, but is a measurement of payments that did not meet Medicare requirements. 

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How Does the CERT Process Work? 

A stratified random sample of Medicare FFS claims is selected for review; an ADR is issued to retrieve the supporting documentation from the provider or supplier who submitted the claim for payment; and the documentation is reviewed by independent medical reviewers to determine if the claim was paid properly under Medicare coverage, coding, and billing rules. 

The CERT RC attempts initial telephone contact with the provider to explain the program and follow up with a faxed or mailed ADR. The provider shall respond to the ADR and forward documentation to support all services and dates of service indicated on the selected claim. 

If the provider fails to submit all medical records to support the claim billed, the claim is counted as either a total or partial improper payment and the improper payment may be recouped (for overpayments) or reimbursed (for underpayments). The error is then categorized into one of five major categories: (1) No Documentation, (2) Insufficient Documentation, (3) Medical Necessity, (4) Incorrect Coding, or (5) Other. 

The last step in the process is the calculation of the annual Medicare FFS improper payment rate, which is published in the HHS AFR. 

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Check here the most common cases with PT, Diagnostics, Psychiatry/Psychology and Hospital Discharge. 

Physical Therapy Services:

Insufficient Documentation Causes Most Improper Payments 

Below is a list of the most common reasons that caused improper payments for physical therapy: 

  • Initial evaluation
  • Initial signed and dated plan of care
  • Updated signed and dated plan of care
  • Time spent for the therapy services
  • Electronic signature or legible signature of the performing provider 

Initial evaluation: The initial evaluation should document the necessity of a course of therapy through objective findings. 

Individualized plan of care: The plan must state the type, amount, frequency, and duration of the services to be furnished and indicate the diagnoses and anticipated short and long-term goals. The plan of care must be signed and dated by the performing and ordering provider.

Updated plan of care: The plan must state the type, amount, frequency, and duration of the services to be furnished and indicate the diagnoses and anticipated short and long-term goals. The plan of care must be signed and dated by the performing and ordering provider.

Time: The total treatment time includes the minutes for the timed code treatment and untimed code treatment.

Signature: An electronic signature or legible signature is required on all notes.

For more information on outpatient physical and occupational therapy, see LCD for Outpatient Physical and Occupational Therapy Services (L33631).

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Diagnostic Testing Services:

Insufficient Documentation Causes Most Improper Payments

Below is a list of the most common reasons that caused improper payments for diagnostic testing services. 

Physician order or intent to order: The physician who is treating the beneficiary must order all the diagnostic tests. The treating physician is a physician who furnishes the consultation or treats the beneficiary for a specific medical problem and uses the results in the management of the specific medical problem. The progress notes should clearly indicate all tests to be performed. The documentation to support the intent to order would be a signed progress note, signed office visit note, or signed physician order.

Medical necessity: Documentation in the patient’s medical record must support the medical necessity for ordering the diagnostic service per Medicare regulation and applicable national coverage determinations (NCD). 

Keep these medical records available upon request:

  • Progress notes or office notes
  • Physician’s order/intent to order
  • Diagnostic test results
  • Attestation/signature log for illegible signature   
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Psychiatry and Psychology Services:

Insufficient Documentation Causes Most Improper Payments

Information frequently missing were: 

  • Initial evaluation: Psychiatric diagnostic evaluation is an integrated psychosocial assessment, including history, mental status and recommendations. The evaluation may include communication with family or other sources and review and ordering of diagnostic tests.
  • Individualized treatment plan: The plan must state the type, amount, frequency, and duration of the services to be furnished and indicate the diagnoses and anticipated goals. (A plan is not required if only a few brief services will be furnished.)
  • Updated treatment plan: An updated treatment plan must be included in the medical record which includes a periodic summary of goals and progress toward goals. Prolonged periods of psychotherapy must be well-supported in the medical record describing the necessity for ongoing treatment.
  • Time (length of session): The medical record must indicate the time spent in the psychotherapy encounter with the patient. The total time can be noted or the time in and time out. 
  • Signature (of the performing provider): An electronic signature or legible signature is required on all notes.
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Hospital Discharge Summary:

Insufficient Documentation Causes Most Improper Payments 

Below is a list of the most common reasons that caused improper payments for hospital discharge services: 

  • Missing documentation that support a face-to-face encounter with the patient;
  • Missing time spent on the discharge summary;
  • Missing electronic signature or legible signature of the performing provider

The hospital discharge summary codes are to be used to report the total duration of time spent by a physician for final hospital discharge of a patient. The codes include, as appropriate, final examination of the patient (face-to-face encounter), discussion of the hospital stay, even if the time spent by the physician on that date is not continuous, instructions for continuing care to all relevant caregivers, and preparation of discharge records, prescriptions and referral forms.

  • 99238 – Hospital discharge  - 30 minute or less
  • 99239 – Hospital discharge – more than 30 minutes
    • If the code in question is 99239 and the time is not indicated in the medical records, CERT will downcode the service to the lower level code 99238 
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Need more info? Read here.

Having all papers in place and properly documented is the first step to protect yourself from failing the CERT testing. Of course, the codes and diagnoses you use for reporting must be correct and up to date. Keep an eye on ICD/CPT updates to not miss anything important. The code you used for years may become invalid or unspecified or even be deleted. Although this is not a contracted obligation, your WCH account representative may also inform you about significant changes or updates, so you won’t miss it.   

CERT can be a pain, but there is also an opportunity to become more attentive and disciplined, when records request will not occur your anxiety.  

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Insights
October 2018