CMS CERT FINDINGS: Insufficient Documentation Errors Leading Cause of Overpayments

A recent update from the American Institute of Healthcare Compliance (AIHC) reminds us that CMS has a MedLearn (MLN) Fact Sheet titled “Complying With Medical Record Documentation Requirements.”

THE PROCESS

The MLN Fact Sheet describes CMS due diligence program called CERT.

The CMS CERT Program measures improper payments in the Medicare FFS Program.
The CERT Program is managed by two contractors, the CERT Statistical Contractor (CERT SC) and the CERT Review Contractor (CERT RC). The Statistical Contractor determines how claims will be sampled and calculates the improper payment. The Review Contractor requests medical records from providers and suppliers who billed Medicare. The Review Contractor reviews the selected claims and associated medical records for compliance with Medicare coverage, coding, and billing rules.

THE ERROR FINDINGS

The MLN Fact Sheet lists common procedures often found with insufficient documentation by the CMS CERT Program. These common procedures and findings include:

Vertebral Augmentation Procedures (VAPs)
● Missing signature and date
● No evidentiary radiographs performed to support medical necessity
● Insufficient medical record documenting that the provider tried conservative medical management but it failed or was contraindicated
● No signed and dated attestation statement for the operative report if a physician signature was missing or illegible; if the operative report is electronically signed, the protocol should also be submitted

Physical Therapy (PT) Services
● Documentation did not support certification of the plan of care for physical therapy services.
● The physician’s/NPP’s signature and date of certification of the plan of care or progress note indicating the physician/NPP reviewed and approved the plan of care is required.

Evaluation and Management (E/M) Services
● Office Visits Established, Hospital Initial, and Hospital Subsequent were identified as the top three CERT errors in E/M service categories
● High errors rates of insufficient documentation, no documentation, and incorrect coding which supported the medical necessity and accurate billing of the E/M services

Durable Medical Equipment (DME)
● Certain DME HCPCS codes (such as, hospital beds, glucose monitors, and manual wheelchairs) require a valid detailed written order prior to delivery
● The physician’s NPI must be on the valid detailed written order
● Medicare will pay claims only for DME if the ordering physician and DME supplier are actively enrolled in Medicare on the date of service
● As a condition for payment, a physician, PA, NP, or CNS must document a face-to-face examination with a beneficiary in the 6 months prior to the written order for certain items of DME

Computed Tomography (CT) Scans
● Documentation of the plan or intent to order a CT scan was insufficient to support medical necessity.
● If the handwritten signature is illegible, include a signature log, and if electronic, the protocol should also be submitted.

THE FINANCIAL IMPACT

CMS CERT Program reports $25.03 billion in improper payments in 2021.

Do you know your organization’s exposure to documentation errors?

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