LEEDer Group Inc.
8508 North West 66th St.
Miami, Florida 33166 USA

Phone: 305.436.5030
Fax: 305.436.0086
E-mail Address: info {at] LEEDerGroup [dot] com

2011-07 CERT Ask the Contractor Q&A

July 28, 2011: Comprehensive Error Rate Testing (CERT) and Medical Review Documentation Errors Ask the Contractor Teleconference: Questions and Answers
  • What is CERT?
    The Centers for Medicare & Medicaid Services (CMS) established the Comprehensive Error Rate Testing (CERT) program to monitor and report the accuracy of Medicare fee-for-service (FFS) payments. The CERT program measures the error rate for claims submitted to Medicare contractors. Palmetto GBA uses CERT reports to identify areas of focus for Provider Outreach & Education efforts. One of the major outcomes of these CERT reports is the paid claims error rate (percentage of dollars paid incorrectly).
  • How are claims selected for review and are we notified if we billed incorrectly?
    CERT randomly selects a sample of approximately 50,000 claims during each reporting period. Medical records are requested from the health care providers. The medical records received are reviewed for Medicare coverage, coding, and billing rules. If errors are found then they are assigned. If the medical records are not submitted by the provider, the claim is automatically counted as an error and an overpayment letter/notice is sent to the provider.
  • How will a provider be alerted that one of their claims was selected for CERT review?
    A letter is sent to the provider by the CERT contractor. The letter will include the CMS logo, be in a manila-colored envelope with a return address showing it was from CMS and the CERT Operations Center. The envelope will show it is a time sensitive request for medical records.
    The request will include the date of service, type of service and specific patient and provider information. The request must be returned by the deadline to the CERT contractor along with the original bar-coded request letter and documentation.
  • Will Palmetto GBA ever ask for medical records?
    Yes. Palmetto GBA may request medical records to support a billed claim on either a pre- or post-pay review.
  • Are the medical record documentation requirements the same for CERT reviews and Palmetto GBA pre- and post-payment reviews?
    Yes. Signature requirements and medical record documentation requirements are the same. Palmetto GBA has Web pages dedicated to CERT and the E/M help center. Be sure to review the article about signature and documentation requirements. Note there are additional CMS documentation resources.
  • If a provider has documented the work to support a certain level of E/M service, must the provider also document the medical necessity?
    The evaluation and management code chosen must both reflect the work that was performed by the physician and that must be complimented by the ICD-9 code that shows why the patient was being treated. If the patient did not require a higher level E/M code then the code should be submitted to reflect the appropriate level of care.
  • I’m not sure I understand all the signature requirements or what a signature log or signature attestation statement is. Where can I find more details?
    Here are some excellent resources are available on the Palmetto GBA, J11 Part B Web site that detail the requirements for medical record signatures, signature logs, and signature attestation statements.
  • Is there a checklist available to help my practice make sure we send all the necessary documentation necessary to document E/M services?
    Yes. Palmetto GBA makes a checklist available on the Web site. We also encourage you to use the E/M score sheet tool as well.
  • What are some of the common problems or deficiencies seen in medical records?
    Support of medical necessity
    Records received for the wrong patient or date of service
    Incomplete documentation
    Illegible signatures
    No signatures or incomplete signatures
    Illegible or blank pages included with the medical documentation
    Incorrect modifier use for procedure/service billed
    Truncated diagnosis codes or discrepancies in diagnosis code billed and diagnosis codes listed in medical records
    Failure to submit copies of Advanced Beneficiary Notice of non-coverage when the modifier GA is submitted
    Billing incorrect place of service
    Unbundling codes bundled by the National Correct Coding Initiative
  • Details on how to correctly bill and avoid these common errors can be found on the Palmetto GBA Web site.
  • Why might Palmetto GBA or the CERT contractor indicate that documentation was illegible?
    Faxed documents must be correctly aligned; they cannot be too light (red ink) and then cannot be blurred. Please use one-sided documents that are readable.
  • If a claim is rejected because the information submitted was invalid, incomplete, or not provided, is that considered an error?
    Yes. These claims are rejected and do not have appeal rights. The claim must be corrected and resubmitted to Palmetto GBA as a new claim. This delays the provider in receiving timely payments.
  • If I submit a claim to Medicare first instead of the patient’s primary insurance, is this considered a claim submission error?
    Yes. All providers must submit claims to the patient’s primary insurance company. If you’re unsure then please use the Online Provider Services (OPS) self-service tool or the Interactive Voice Response (IVR) system to verify patient eligibility.
  • How can I know if a particular service is included in a Local Coverage Determination (LCD)?
    Open up the CMS LCD Web page, click on advanced search tool located at the top of the CMS LCD page and then search by policy, or a specific CPT/HCPCS code.
  • Can a provider submit a claim prior to the medical record being completed?
    No. Providers should not bill Medicare until the medical record is complete. Submitting services that are not documented is inappropriate.
  • If one of my claims is reviewed by either the CERT contractor or Palmetto GBA will I get notice of the findings?
    Yes, if errors are found during a prepay review; the claim will result in no payment or partial payment. If an error is found during a CERT review, the provider will be sent a CERT Tip letter. The letter alerts the provider of the error, provides educational resources, and gives details regarding how the provider can appeal the decision.
  • Can a provider appeal a CERT error?
    Yes. Providers who disagree with the CERT contractor’s decision may appeal the decision. You are encouraged to carefully review the CERT Tip Letter and understand why the CERT error was assigned.
    Check with your medical records department to see what records were supplied
    Examine the denied services and compare them to the records that were sent to the CERT contractor
    Verify that the corresponding entry supports the date of service, procedure code, diagnosis code, modifier, and quantity billed
    Verify that medical necessity and specific coverage requirements are documented
    Verify that medical records clearly indicate the patient’s name and other identifying information is included on each documentation page
    Verify legibility of records
    Verify signature requirements are met
    For electronic records, make sure that you sent the final or signed report not an interim or unapproved report
  • CERT errors are an important indicator for a practice that documentation or billing practices should be changed. This is a great opportunity to take corrective steps and prevent future errors.
  • As it relates to a detailed exam, does Palmetto GBA require an examination and documentation of at least two items in two different organ systems?
    Yes. Palmetto GBA has two self-service tools that providers can use to audit their records or to assist in code selection. The tools are the E/M Scoresheet Tool, Established Patients and the E/M Scoresheet Tool, New Patients.
  • Sometimes one provider in a group will order a service but when the patient returns to have the service provided, the ordering physician is not present but another member of the group is present. Should we bill under the ordering provider or the supervising provider and whose signature should be in the record when the service is performed?
    The service should be billed under the NPI of the provider that performs the E/M service (if all incident rules are met). The medical record should be signed by the provider that is in the office providing the supervision. The ordering physician should document the services ordered, intent of the service and medical necessity in the patient’s record.
  • When Palmetto sends out a CERT Tip letter because and error has been identified, can that be sent to a specific person in the practice?
    No. The letters are mailed to the pay-to address on file for the provider who performed the service.
  • If I want to know the status of a CERT review and I call the CERT contractor they refer us back to Palmetto GBA. What will Palmetto GBA be able to tell us about the review?
    Palmetto GBA will only be able to tell you whether the review has been completed. We cannot tell if an error was found or any specifics.
  • In a teaching setting, can one physician assist another during a surgical procedure (assuming that an assistant surgeon is allowed for the procedure) if the two physicians are of different specialties?
    Carriers do not pay for the assistant services for surgery furnished in a teaching hospital that has a training program related to the medical specialty required for the surgical procedure if there is a qualified resident available to perform the service. Check the manual to determine what exceptions apply. The CMS Internet Only Manual (PDF, 990 KB), Publication 100-4, Chapter 12. Section 100.1.7 outlines these exceptions.
  • Please explain how a physician and a NP or PA can split or share an initial inpatient visit and who should bill for the service?
    If there is a face-to-face encounter shared between a physician and a nonphysician practitioner (NPP) from the same group, the E/M service may be submitted by either of them.
    If there was no face-to-face encounter between the patient and the physician (e.g., even if the physician participated in the service by only reviewing the patient’s medical record) then the service must be billed under the NPP’s NPI.

last updated on 08/19/2011