CERT Audit Identifies Top Billing Errors

You may or may not be surprised by what Trailblazer’s Comprehensive Error Rate Testing (CERT) audit in Colo., N.M., Okla., and Texas found to be the top Part B billing errors.

Insufficient Documentation

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Insufficient documentation errors because the documentation did not include the date of service, the patient’s name, or a legible provider identifier are the most noteworthy.

Some claims fail simply because signature requirements are not met. Medicare requires records contain a signature or legible identifier for every service reported. Your physician’s signature can be either handwritten or electronic, but stamped signatures (eg, rubber stamps) are not acceptable. Include a signature log if the signature isn’t legible and an attestation statement if there is no signature at all. Other errors include:

  • Incomplete hospital record (13 percent)
  • Incomplete or missing plan of care
  • Records for wrong date of service
  • Incomplete physical, occupational, or speech therapy records
  • Missing results for diagnostic or laboratory test
  • The valid ICD-9-CM code submitted was insufficient

Medically Unnecessary Services

For Medicare to determine a service to be medically reasonable and necessary, that service must be:

  • Safe and effective
  • Not experimental or investigational
  • Appropriate in duration and frequency
  • Performed in accordance with accepted standards of medical practice
  • Furnished in an appropriate setting
  • Ordered and furnished by appropriate personnel
  • Meeting but not exceeding the patient’s medical need

To be paid for diagnostic tests, the physician must order the test with the documentation providing evidence of intent for the tests to be performed. In other words, make sure the physician signs the documentation.

Incorrectly Coded Services

Not surprisingly, most incorrect coding errors reported by the CERT contractor are related to evaluation and management (E/M) services, including:

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  • E/M does not meet level required (66 percent)
  • Services coded incorrectly
  • Illegible documentation service was denied or down-coded
  • Exam component not meeting the level required
  • History component not meeting the level required
  • Service not meeting the definition of a new patient
  • Service not meeting the definition of critical care

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