January 19, 2007
Comprehensive Error Rate Testing (CERT) Tips for Documenting
One of the required elements in the Comprehensive Error Rate Testing process is requesting documentation to support every item billed on the claims sampled claims. Many errors are found because there is lack of appropriate documentation. When errors are found and claims were paid in error, refund requests are submitted to the providers. To assist you, below are helpful tips for claim documentation and the CERT process.
What Documentation to Submit When A Request for Records is Received:
Each charge on the claim should be supported with the following:
- Documentation to support the medical necessity
- Documentation that the procedure/service was performed
- Documentation that reflects the correct name and date of service identified on the claim
If there is no supporting documentation that the procedure/service was performed, there will be no reimbursement.
- The medical record should be complete and legible.
- Each patient encounter should include:
- the date
- the reason for the encounter
- appropriate history and physical exam
- review of lab, x-ray data and other ancillary services
- assessment and a plan of care, including discharge plan (if appropriate)
- Past and present diagnoses should be accessible to the treating and/or consulting physician
- Reasons for and results of x-rays, lab tests and other ancillary services should be documented or included in the medical record
- Relevant health risk factors should be identified.
- Patient’s progress, including response to treatment, change in treatment, change in diagnosis, and patient non-compliance should be documented.
- The written plan of care should include, when appropriate:
- Treatments and medications, specifying frequency and dosage
- Any referrals and consultations
- Patient/family education
- Specific instructions for follow up
- The documentation should support the intensity of the patient evaluation and/or treatment, including thought processes and the complexity of medical decision-making
- All entries to the medical record should be dated and authenticated by the physician/provider signature.
- The CPT/ICD-9-CM codes reported on the CMS-1500 form should reflect the documentation in the medical record.
Remember:
- Clearly document the need for each service, especially if it is not related to the presenting problem.
- Clearly and legibly document the services rendered in the medical record.
- Bill the CPT/ICD-9-CM codes that most accurately reflect the services rendered and documented.
- Acceptable documentation is based on medical necessity, not volume of documentation.
- CERT allows 75 days for initial requests for documentation and 15 days for tech stop (request for additional documentation) requests.
