By Chris Fraizer, CPC, CPC-H, CPC-P
Documentation no longer holds first place for claims rejection, according to the latest results of the Comprehensive Error Rate Testing (CERT) program of the Centers for Medicare and Medicaid Services (CMS). But the not so good news: Coding errors now hold that distinction (see accompanying table). “Coding errors are skyrocketing,” says Diana Lerro, BSN, RN, CPC-H, of United Government Services, LLC, a CERT contractor. “We see all sorts of errors, anything from the wrong revenue code to an incorrect HCPCS code.” Lerro added that this doesn’t mean documentation is flawless, said Lerro. “Providers have learned what to look for in their documentation, and as the errors in documentation decreased, the coding slice of the pie got bigger,” she says. The same should apply to future coding results. Aggregate data could for example, point out specific weaknesses in guidelines resulting in recurring issues or, on an individual basis, the CERT audit could suggest a workload that invites error, the use of outdated coding manuals or the failure to update superbills. “The numbers could go down once the problems are identified,” Lerro says. “Often times, it’s a mistake the carrier hasn’t picked up and it continues to happen.” The error rates are reported in May and November of each year. The CERT report, based on a random selection of 13,000 claims, released the figures below in November 2006.
A common error involved overcoding or undercoding E&M codes by one level on a scale of five code levels. Published studies suggest that under certain circumstances, experienced reviewers may disagree on the most appropriate code to describe a particular service. This may explain some of the incorrect coding errors in this report. CMS is investigating procedures to minimize the occurrence of this type of error in the future.
CERT Program Overview
Centers for Medicare & Medicaid Services (CMS) developed the CERT Program in 2000 to calculate error rates for carriers, durable medical equipment regional carriers (DMERCs), and fiscal intermediaries (FIs), through a random selection of claims from health care providers across the country. The CERT contractor randomly requests an average of 200 or more claims each month from the provider addresses listed in the system, then the contractor requests the records for review. CERT will send up to four letters and three phone calls requesting the records and the provider has 90 days before the claim is counted toward the Provider Compliance Error Rate.
CERT medical review specialists examine the medical records received to determine the following information:
- Does the service fit a Medicare benefit category?
- Is the service statutorily excluded?
- Does the service meet the definition of medically reasonable and necessary?
- Does the documentation support the service that was performed?
- Are the services reported, coded and billed correctly?
The CERT contractor sends the file to the carriers or fiscal intermediaries, and that file includes all the denied claims. The claims are adjusted and the providers are notified. If the provider disagrees with the CERT initiated denial, the claim may be appealed using the Medicare guidelines that apply to other payment appeals. But it’s not only the providers the CERT program affects. The CERT contractor takes the results and calculates the paid-claim error rate for individual Medicare carriers, geographic areas, and medical specialty categories, along with the overall national error rate. Medicare Part A and Part B carriers, CMS and the Office of the Inspector General monitor the sampled data and the decisions of the independent medical reviewers. CERT findings can lead to corrective action plans in situations where error rates are high.
What are Your Odds for CERT Review?
The CERT sampling process is totally random. The chance of your physician getting hit with a CERT audit is unknown until the day the distinctive letter arrives. Instead of gauging the uncertainty and worrying over the unknown, Lerro suggests a proactive response if the letter does arrive at your practice. “Read the letter and respond,” said Lerro. “Consider it a heads up since we’re not the only ones out there looking for correct coding.” The errors CERT uncovers will probably apply to other payers as well. In the long run, who knows what CERT could do for coding. Coding errors could go the way of documentation issues, no longer taking first place.