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March 22, 2012 - Revised: 10.03.13

Top CERT Denial Reasons for Inpatient, Skilled Nursing Facilities, and Outpatient Claims

This article is intended to highlight the Comprehensive Error Rate Testing (CERT) denials that appear frequently for inpatient, skilled nursing facility and outpatient claims and to encourage J15 Part A providers’ assistance by ensuring that they do not contribute to the J15 Part A claims paid error rate due to poor documentation.

J15 Part A providers control the documentation describing what services their patients received. This documentation serves as the basis for the claim submitted to Medicare for the services rendered. If the submitted documentation does not support the services listed on the claim, then a payment error exists.

To help lower the paid claims error rate, CGS will be monitoring the CERT error rate to determine which documentation errors occur on a regular basis and focus on those services with significant issues when performing medical review. We will increase the level of frequency of pre-payment medical review of claims across all provider types and services. CGS will also supply providers with the tools necessary to comply with the Medicare program coverage and billing requirements, as well as the documentation needed to support these requirements.

The main factors that contribute to the claim payment error rate determination for inpatient claims are:

Insufficient documentation errors occur when:

Medically unnecessary services are categorically the result of:

DRG changes due to wrong diagnosis or wrong principal diagnosis code are due to:

DRG change due to wrong procedure code occurs when:

The main contributors to the claim payment error rate determination for SNFs involves insufficient documentation to support the Resource Utilization Group (RUG) code billed resulting in a downcode and no documentation of qualifying medically necessary three day inpatient hospital stay.

Insufficient documentation to support the RUG code billed resulting in a downcode occurs when:

No documentation of qualifying medically necessary three-day inpatient hospital stay occurs when:

The main contributor to the claim payment error rate determination for outpatient claims involves missing or ineligible physician signatures. The following article Medicare Medical Records: Signature Requirements, Acceptable and Unacceptable Practices can be used as a reference concerning Medicare guidelines for physician’s signatures.

Providers who received or receive a CERT denial should review the documentation they submitted. If the provider disagrees with the denial or if they believe in their original submission they omitted documentation that would support payment, please follow the steps below to appeal.

CGS
J15 Part A Appeals
PO Box 20006
Nashville, TN 37202

Claims payment reviews are conducted by CGS or one of the several Centers for Medicare & Medicaid Services (CMS) payment review contractors (Recover Audit Contractor (RAC), Zone Program Integrity Contract (ZPIC), CERT), requesting documentation from sample of claims from a provider’s submission. Documentation that does not support the service or fails to comply with medical record/documentation requests results in a claim denial. When the volume of a provider’s documentation (missing, insufficient or billed incorrectly) is found to be unacceptable, CGS will take any or all of the following additional actions:

All J15 Part A health care professionals are encouraged to help in this effort by ensuring the following:

Reducing Medicare errors and payments for claims with insufficient/missing documentation or billing errors requires a team effort. We encourage you to share this information with everyone on your staff to ensure that your claims and their supporting documentation are properly maintained.


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