2018 CERT Analysis

CMS has not released a full Comprehensive Error Rate Testing (CERT) report since 2016. But, the 2018 supplemental report provides ample information about areas of risk, error and concern in medical practice coding.

CMS hires an independent contractor to randomly review claims of all types, Part A, Part B, durable medical equipment, and home health services from all parts of the country. The claims for review are selected at random, and only services with over 30 claim lines (only codes that are in the sample at least 30 times) are included in the analysis of improper payments. Improper payments include overpayments and underpayments. Both are calculated in the error rate.

Audit requests from a CMS contractor

Any practice receiving a request for notes from any CMS contractor should respond and provide those notes. Don’t ignore the request. Do respond to the request, following the directions for submitting the documentation precisely.

There are many types of audits and some requests are more ominous than others. A request from a Recovery Audit Contractor (RAC) or from the Zone Program Integrity Contractor (ZPIC) or from the Office of Inspector General (OIG) should be turned over the compliance department, chief executive or administrator or medical director in your practice immediately! Run, don’t walk. Talking to your health care attorney would be prudent.  Those requests are not random.

Your Medicare Administrative Contractor (MACP may also request notes, sometimes before the claim is paid.  These Additional Document Requests (ADR) or probe audits are often related to an issue that the MAC is interested in, such as subsequent hospital visits billed at the highest level, 99233. They can also be provider specific, based on a coding pattern.  Respond to these requests and monitor how the claim is processed after the MAC receives the note. If the payer is down coding your claims, do an internal review and provide education, if needed.

CERT requests really are random, and don’t indicate that your practice is under scrutiny. Of course, a Medicare contractor is reviewing you record, so do an internal review of that record. Be careful and complete in your submission.

2018 CERT results

CERT identifies universal errors are those that are missing or have inadequate orders, inconsistent records and missing or inadequate records. Some records have more than one universal error.

The specific type of errors found in the documentation for Part B claims includes no documentation, insufficient documentation, medical necessity, incorrect coding and other. The report itself doesn’t define insufficient documentation, but the CGS Medicare website as

“Claims are determined to have insufficient documentation errors when the medical documentation submitted is inadequate to support payment for the services billed, i.e., the reviewer could not conclude that some of the allowed services were actually provided, were provided at the level billed, and/or were medically necessary. Claims are also placed into this category when a specific documentation element that is required as a condition of payment is missing, such as a physician signature on an order, or a form that is required to be completed in its entirety.”

Summarized that is:

• An incomplete progress note
• Un-authenticated medical record (signature issue)
• No documentation of intent to order services or procedures, incomplete or missing signed order or progress note.

No documentation can mean “there was no documentation” or “the practice didn’t send us any documentation and we counted that as no documentation.”

Not surprisingly, initial and subsequent hospital visits, emergency department visits and critical care have a high error rate due to incorrect coding.  In the category “other drugs,” there was a 9.1% error rate, and 65% of those errors were classified as having insufficient documentation. (Dosages, anyone?) Minor procedures have a 15% error rate, and 91% of those were classified as having insufficient documentation.  For musculoskeletal minor procedures, there was an astonishing 29% error rate, with 86% having insufficient documentation and 13% classified as errors due to medical necessity.

Medical practices can learn from these reviews. Use the CERT results to select types of records to audit, to improve templates and as a focus for education. You can download the CERT report for and read it for yourself.

Watch the on-demand webinar in which I discuss these and other findings in more detail and interpret the report.

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