April 14, 2008
Comprehensive Error Rate Testing (CERT)
Decreasing the CERT Error Rate
Providers help decrease the CERT error rate by sending all documentation requested to support the services billed on the sampled claim chosen by the CERT contractor. Prior to faxing/mailing documents providers should verify the following:
- 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
- Include all additional supporting documentation from a third party (hospital, nursing home, etc.), as necessary
- The CPT/ICD-9-CM codes reported on the CMS-1500 form should reflect the documentation in the medical record
- The CERT barcoded cover sheet with the Claim Identifier (CID) precedes the medical record to be faxed. If the barcode sheet is not available please write the CID number (also located at the top of the Pull List sent with the request) at the top of each page of your fax.
Providers will be asked to submit their medical record documentation in accordance with the following time standards.
Day 0: Initial Call/Letter
Day 30: Second Call/Letter
Day 45: Third Call/Letter
Day 60: OIG Letter
Day 76: Claim scored in error
Should you have any problems providing the documentation requested you may call the CERT Documentation Contractor at (888) 779-7477, please have the CID of the claim in question available when you call.
REMEMBER:
No response = no records = overpayment = taking money back
