License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

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POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

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Comprehensive Error Rate Testing (CERT) Program Frequently Asked Questions

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What is CERT?
- The Centers for Medicare & Medicaid Services (CMS) implemented the Comprehensive Error Rate Testing (CERT) Program to measure improper payments in the Medicare Fee-for-Service (FFS) program. CERT is designed to comply with the Improper Payments Information Act (IPIA) of 2002, as amended by the Improper Payments Elimination and Recovery Improvement Act (IPERIA) of 2012.
  
  Reviewed: 12.13.16
How does the CERT process work?
- CERT selects a stratified random sample of approximately 40,000 claims submitted to Part A/B Medicare Administrative Contractors (MACs) and Durable Medical Equipment MACs (DMACs) during each reporting period. This sample size allows CMS to calculate a national improper payment rate and contractor- and service-specific improper payment rates. The CERT program ensures a statistically valid random sample; therefore, the improper payment rate calculated from this sample is considered to reflect all claims processed by the Medicare FFS program during the report period. The sample of Medicare FFS claims is reviewed by an independent medical review contractor to determine if they were paid properly under Medicare coverage, coding and billing rules. If these criteria are not met or the provider fails to submit medical records to support the claim billed, the claim is counted as either a total or partial improper payment and the improper payment may be recouped (for overpayments) or reimbursed (for underpayments). The last step in the process is the calculation of the annual Medicare FFS improper payment rate, which is published in the Health and Human Services (HHS) Agency Financial Report (AFR).
  
  Reviewed: 12.13.16
What information is sent to providers when a claim is selected by CERT?
- A letter is sent to the provider indicating that a claim has been selected for CERT review. The letter consists of several pages, including instructions for submitting your medical records, the timeframe by which the documentation must be received, and specific information to identify the claim that was selected. One page is a bar coded sheet that lists the specific documentation being requested for the claim. The letter also contains the FAX number for which documentation should be sent to. Sample letterscan be accessed from the CERT Provider website.
  
  Reviewed: 12.13.16
What should we do if our claim is selected for a CERT review?
- - Review the bar coded sheet, included with the CERT letter, to determine what documentation is being requested
  - Keep a copy of the CERT letter, including the bar coded sheet, on file within your agency
  - Gather all documentation requested in the letter, and any additional documentation that supports the coverage and medical necessity of all services billed for the dates of service indicated on the request
  - Photocopy each record. Make sure all copies are complete, legible, and contain both sides of each page
  - Place the bar coded cover sheet in front of the documentation
  - Submit the documentation within the requested timeframe to the CERT Documentation Center (CDC)
    - FAX (240.568.6222) or CD in TIFF or PDF format (preferred methods)
    - Please email the password to certmail@admedcorp.com with your CID number in the subject line.
    - Electronic Submission of Medical Documentation (esMD)
  Updated: 12.13.16
How long do we have to send in the requested documentation?
- You have 75 days after the initial request letter to send in your documentation. It is suggested that you send your documentation as soon as possible. Beginning on the 30th day of the initial request, if your documentation has not been received, the CERT Documentation Contractor will send additional request letters, and you may receive a phone call from the CERT Medical Records Specialist. CGS will also call you to ensure you respond to the requests. By responding promptly, you will eliminate additional letters and phone calls.
  
  Reviewed: 12.13.16
What can we do to ensure our documentation is received timely?
- - Be alert to requests from the CDC. A sample of a CERT envelope can be viewed at the CERT Provider website.
  - Designate a CERT point of contact for your agency who will be responsible for receiving the request letters and/or telephone calls and for ensuring they are responded to timely
  - Post a sample copy of the request letter where the mailed requests are likely to be received with instructions indicating to whom it should be routed
  - Alert staff responsible for answering the telephone about the CERT process and give them instructions indicating to whom the call should be routed
  - Make sure your main provider address and telephone number are correct as submitted on the provider enrollment form (CMS 855-A). If it is not correct, or if you have questions about submitting a corrected form, contact the CGS Provider Contact Center at 877-299-4500 (select Option 1).
  - For questions or comments related to the Request for Medical Records, you may call the CERT Customer Service Representative at (888)779-7477 or (443) 663-2699
  Reviewed: 12.13.16
How can we ensure our CERT point of contact information is current and how can we make changes if needed?
- To verify who your designated CERT point of contact is, you can access the "Provider Address Directory" on the CERT Provider website. Enter in your National Provider Identifier (NPI), or your Provider Transaction Access Number (PTAN) in the "Provider ID" box. You must also enter the Contractor ID, which is 15004 (for home health and hospice providers who bill to CGS). Then click "Search". From here, you can view your agency's name and address, the designated CERT point on contact that is on file with CERT, and the phone and fax numbers for your agency. This page also contains a "Change Contact Information" link to request a change be made to your contact information, or, to establish a contact person if you are a new provider.
  
  Reviewed: 12.13.16
Do we need the beneficiary's authorization to release the information to the CERT contractor?
- No, Medicare beneficiaries have already given authorization to release medical information in order to process claims. It is not a HIPAA violation to submit documentation to the CERT contractor.
  
  Reviewed: 12.13.16
Do we need to obtain all the documentation/information from our associated providers?
- Yes, it is the responsibility of the billing provider to respond to the request for medical records related to the care you provided. This includes all medical records that reside with a third party (e.g. clinics, labs, hospitals, physicians).
  
  Reviewed: 12.13.16
Who are the errors assessed to?
- The errors are assessed to the Medicare Administrative Contractor (MAC) and the provider who billed the services. When an error is determined, the claim is adjusted by the MAC (e.g. CGS). Providers are notified of claims denied by CERT via their Remittance Advice (RA) or Electronic Remittance Advice (ERA). Provider can appeal any denial received as a result of a CERT review.
  
  Reviewed: 12.13.16
What outcomes are expected from the program?
- The CERT Program supports CMS's primary objectives of ensuring that Medicare contractors are paying claims appropriately, and providers are billing medically necessary services correctly. The error results help identify the areas of greatest vulnerability to the Medicare program, and will assist in directing educational activities to reduce the error rates.
  
  Reviewed: 12.13.16
What if we have additional documentation that we did not originally send with the request?
- You may send additional documentation to the CERT Documentation Center (CDC) at any time, even if it is after the requested time frame. Be sure to include a copy of the bar coded cover sheet to identify the claim identification (CID) number associated with your documentation.
  
  Updated: 12.13.16
Why would the CERT contractor consider my claim an error?
- Errors may result for the following reasons:
  - No Documentation Received
    - This results when the provider fails to respond to the request for medical records, or responds to the request untimely. In order to avoid these types of errors, be sure to respond within the timeframe indicated on the request.
  - Insufficient Documentation
    - The majority of errors are due to insufficient documentation. In order to avoid these types of errors, be sure to submit all applicable information to support the services billed on the claim, and listed on the documentation checklist included in the CERT request. Remember, it is your responsibility to gather any supporting documentation from third parties such as hospitals, labs, skilled nursing facilities, or ordering physicians, etc.
  - Medically Unnecessary Services or Treatment
    - All services provided to Medicare beneficiaries MUST be medically necessary. Documentation to support that medical necessity must be submitted for review. Submit all applicable information that supports the medical necessity such as physician's orders, assessments, plans of care, etc.
  - Incorrect Coding
    - These errors result when the documentation submitted supports either a different code, or a different number of services. In addition, the documentation must accurately support the number of service units billed.
      - For home health providers, the documentation must support the answers completed on the OASIS, as well as the HIPPS code submitted on the claim.
      - For Part A and Part B providers, the documentation must support the CPT code as outlined in the AMA CPT book that covers the year in which your service was performed.
  - Improper Documentation
    - This error results when the documentation submitted is for the correct beneficiary and dates of service on the request. To avoid this, be sure to check the request against the records being sent.
  Reviewed: 12.13.16
Is there a way to monitor the status of claims that were selected by CERT?
- Yes, CGS has a CERT Claim Identifier Tool available to our providers to identify the outcomes of their claim's CERT review. To use this Tool, you must have an established email and password. If you do not already have an email and password for the CERT Claim Identifier Tool, you can apply for one at http://www.cgsmedicare.com/medicare_dynamic/cid_tool/apply.asp. Once you have access to the tool, enter the Claim Identifier (CID) number assigned to the claim by CERT, and click 'Submit'. You will see the CERT review date, the date of CERT's letter(s) or phone call(s), if the claim was determined to be in error, and the CERT reviewer's comments.
  
  Reviewed: 12.13.16
What happens if one of our claims receives an error?
- - CGS will adjust the claim, and either recoup money (overpayment) or pay additional money (underpayment).
  - Letters are sent from the CGS CERT Coordinator with details of your error. These letters are faxed to the fax number on file with the CERT office.
  - Sign up for myCGS where you can check on the status of any claim.
  - For Part A and home health and hospice providers, the adjusted claim can be identified in the Fiscal Intermediary Standard System (FISS) with a TOB ending in an "H" (e.g. 13H, 32H, 81H). Remarks indicating the reason for the CERT error will be entered on FISS Page 04.
  Reviewed: 12.13.16
What is a CERT additional documentation request?
- An additional documentation request is sent from CERT when a provider has submitted their documentation, and it has been received by the CERT Documentation Center (CDC); however, CERT is requesting additional documentation. The letter will specify the additional documentation that is being requested and a date that the additional documentation must be received by.
  
  Updated: 12.13.16
Where can I get more information about the CERT program?
- The following list provides additional resources regarding the CERT Program.
  Reviewed: 12.13.16
Who can I contact if I have questions regarding the CERT program?
- You can contact the CGS CERT Coordinator, Julene Mull at 1.615.782.4591.
  
  Reviewed: 12.13.16
Can a CERT error result in a Zone Program Integrity Contractor (ZPIC) referral?
- It is important to note that the improper payment rate is not a "fraud rate," but is a measurement of payments that did not meet Medicare requirements. The CERT program cannot label a claim fraudulent.
  
  Reviewed: 12.13.16

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

AMA Disclaimer of Warranties and Liabilities.

CMS Disclaimer

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

Comprehensive Error Rate Testing (CERT) Program Frequently Asked Questions

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