Documentation

Specific medical record documentation, at the time of an IRF admission, must support a reasonable expectation that the patient needs multiple intensive therapies, one of which must be physical or occupational therapy; the patient must be able to actively participate and benefit significantly from the intensive rehabilitation therapy program; and requires supervision by a rehabilitation physician to assess and modify the course of treatment as needed to maximize the benefit from the rehabilitation process.

Strategies for reducing audit errors caused solely by information missing from the hospital record for DRG Spinal Fusion.

Major joint replacement or reattachment of the lower extremity (DRG 470) is Medicare’s top volume Medicare Severity (MS) – Diagnosis Related Group (DRG)s. Due to the high volume of these claims, CMS has had multiple auditing entities reviewing claims for these MS-DRGs, including the Recovery Auditors, Comprehensive Error Rate Testing (CERT) Contractors, and Medicare Administrative Contractors (MACs), reviewing claims for these MS-DRGs. The findings have demonstrated very high paid claim error rates among both hospital and professional claims associated with major joint replacement surgery.

This CMS video will help providers and physicians understand the need and importance of medical record documentation to support the services billed.

This updated article includes information and instructions on how to respond to a Comprehensive Error Rate Testing (CERT) Documentation Request.

CMS guidelines mandate the presence of signatures for medical review purposes. However, records pertaining to any procedures billed to Medicare are potentially subject to review by not only Palmetto GBA, but other CMS contractors. Because of this, we are alerting you to the importance of these signature requirements and if changes are needed, we suggest you take immediate action.

This CMS Medicare Learning Network fact sheet addresses updated medical record maintenance and access requirements, documentation and best practices.

Part A Outpatient Dialysis services with a bill type of 72X have historically been in the top 10 types of services in error for Comprehensive Error Rate Testing (CERT) reporting periods. When a provider receives a CERT error for no documentation or insufficient documentation, it means that elements of the medical record that are imperative for Medicare payment were not sent into the CERT contractor for review. The most common reason for errors received are related to the billing provider submitting insufficient documentation.

The Medicare SNF benefit pays for certain skilled services provided in various skilled nursing settings, including swing-bed hospitals, nursing homes, and other freestanding facilities; only if the certification and recertification for services meet certain content criteria. There are no specific procedures or required forms for certification and recertification statements.

Medicare providers must comply with documentation requirements, including the timeliness of documentation in connection with the provider signature.

​​​​​​​Palmetto GBA frequently encounters errors assessed by the Comprehensive Error Rate Testing (CERT) Review contractor due to signature problems on submitted medical records, X-ray reports and laboratory/radiology orders. As Medicare providers, you may be asking what significance this has for you. The discovery of CERT errors may lead to increased scrutiny of future  services that you bill to Medicare. Your understanding of this important issue is essential to ensuring the accuracy of your Medicare claims.

All health care providers to enter information into the patient’s medical record at the time the service is provided to the patient; that is, contemporaneously.

When services are denied or down-coded by the CERT Review Contractor and an overpayment is identified, providers are entitled to file a redetermination request with Palmetto GBA.

When a provider receives a Comprehensive Error Rate Testing (CERT) error for insufficient documentation, it means that elements of the medical record that are imperative for Medicare payment are missing from the medical record sent in to the CERT contractor for review. Some tips to prevent this error are included in this updated article.

Avoid mistakes by understanding exactly what your Comprehensive Error Rate Testing (CERT) Contractor Is looking for.

Here are some guidelines for documenting medical records. All information about services performed must be documented. If it isn’t documented, then no one knows what was performed.

The CERT contractor should not be referred to a third party to obtain medical records.

This article applies to providers who bill inpatient claims for the performance of a Transcatheter Aortic Valve Replacement (TAVR).