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March 22, 2012 - Revised: 12.16.14

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 or missing documentation to support services as reasonable and necessary per the Medicare program requirements
  • Diagnosis-Related Group (DRG) change due to wrong diagnosis or principal diagnosis code
  • DRG change due to wrong procedure code

Insufficient documentation errors occur when:

  • Medical documents submitted do not include pertinent patient information (the patient’s condition, diagnosis or types of conservative treatments attempted prior to specific surgeries for particular DRGs billed, etc.)
  • Medical documentation is illegible, has no date, is improperly signed, etc

Medically unnecessary services are categorically the result of:

  • Level of care billed not supported by documentation
  • Undocumented service(s)
  • Improperly documented service(s)
  • Insufficiently documented service(s)

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

  • Not choosing the most appropriate diagnosis or principal diagnosis code based on Medicare guidelines and coverage. As stated in the Uniform Hospital Discharge Data Set (UHDDS) the principal diagnosis should be "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care."

DRG change due to wrong procedure code occurs when:

  • Insufficient documentation is submitted to support the DRG billed
  • Documentation submitted does not adhere to the specific policies outlined in the National Coverage Determination (NCD) for specific diseases and procedures if applicable

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:

  • Medical documents submitted do not contain pertinent patient facts (patient’s condition, types of treatment provide such as wound care, etc.) and/or documentation of therapy minutes or progress notes are not submitted. 

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

  • Insufficient documentation is submitted to support a medically necessary three day inpatient hospital stay or not submitting an authenticated hospital discharge summary for the dates of service in question

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 PracticesPDF 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.

  • Complete the J15 Part A Redetermination FormPDFlocated under the forms section at CGS website. The appeal request must be sent to CGS J15 Part A Appeals department within 120 days from the date of the initial overpayment letter. Also, remember to sign and date the Redetermination Form prior to sending in an appeal request.
  • With an appeal, please submit any additional information with the original documentation to support payment of the services billed. Some examples of documentation to include are:
    • Certifications /recertification for the appropriate date of service
    • Office records/progress notes, any required assessment records
    • Treatment plan/plans and
    • Clear legible physician orders
  • The appeal request should be mailed to:

    J15 Part A Appeals
    PO Box 20006
    Nashville, TN 37202
    Fax: 803.462.2585

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:

  • Expanded prepayment medical review of claims, possible resulting in payment delays
  • Referral to ZPIC for expanded review if warranted

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

  • A proactive approach to reviewing and providing complete documentation as required
  • Process improvements to ensure maintenance of records are consistent with Medicare program rules

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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