Recent CERT Findings - January 2010
The Comprehensive Error Rate Testing (CERT) Program was established by the Centers for Medicare & Medicaid Services (CMS) to monitor the accuracy of claim payment in the Medicare Fee-For-Service program. Cahaba GBA has published recent CERT findings on their What’s New webpage. The findings are an analysis of the data in the November 2009 error feedback file which was derived from claims submitted 4/1/08 – 3/31/09.
The findings indicated that 79% of errors were for types of bill 13X and 14X which include hospital outpatient services. The most significant source of errors for these bill types was the failure to demonstrate medical necessity with a signed physician’s order for laboratory services and diagnostic tests and failure to provide adequate documentation to substantiate the billing of laboratory services and diagnostic tests.
Hospital inpatient services (type of bill 11X) accounted for 7% of the errors. These errors resulted from insufficient documentation, billing for services that demonstrate a lack of medical necessity, billing for the wrong diagnosis and/or procedure codes resulting in the improper billing of a DRG, and billing for services that represent improper utilization of the inpatient setting.
By Error Categories, 65% of the errors received were medical necessity errors which included services lacking adequate physician orders. Submission of insufficient documentation to support services billed, which also included lacking adequate physician orders, accounted for 23% of errors. Approximately 8% of the errors were for billing for services that were coded incorrectly. These included numerous errors for the billing of HCPCS code 85025, CBC with differential WBC, when the documentation indicated that the physician ordered HCPCS Code 85027, CBC. Other coding errors involved units of service and the DRG coding errors mentioned above.
The complete article can be viewed on the Cahaba GBA What’s New webpage: Recent CERT Findings