Cardiology Coding Alert


Discover How CERT Program Works to Protect Your Reimbursement

Hint: When CERT comes knocking at your practice, make sure you answer.

As a cardiology coder, you encounter numerous acronyms in your day-to-day experience such as acute myocardial infarction (AMI); coronary artery disease (CAD); congestive heart failure (CHF); electrocardiogram (EKG); and left anterior descending coronary artery (LAD). And that's just the acronyms you see in your specialty.

Visit and you're instantly inundated with an alphabet soup of letters. CMS even offers a database to help you navigate these acronyms. Head's up - there are 473 entries for the letter "C" alone.

If you want to protect your reimbursement, one acronym you absolutely cannot afford to miss is CERT - the Comprehensive Error Rate Testing program.

What makes CERT important? CERT identifies common medical coding errors and assesses error rates. Read on to learn more about how CERT works and what costly coding mistakes you should avoid in your cardiology practice.

Side-Step Common CERT Cardiology Errors

The Medicare administrative contractor (MAC) Noridian offers a helpful tool on its website where it breaks down common CERT errors by specialty. Here are some common CERT errors caused by insufficient documentation, no documentation, or incorrect coding to avoid in your cardiology practice regarding evaluation and management (E/M), lab, injections, and other CPT® codes:

  • There was missing supportive documentation such as daily notes, progress notes, evaluation, and clinical documentation for the billed EM service.
  • The code did not meet the required key element for the E/M service you billed. Instead, it meets the requirements for a lower-level E/M service.
  • The physician's order or intent and supportive documentation such as lab results, diagnostic report, and visit notes was missing.
  • The services that you billed were not the ones actually rendered.
  • The physician's signature was missing or illegible.

Don't miss: One common problematic code Noridian mentions specifically is 93306 (Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography).

Tip: Something to remember when reporting 93306 is that it requires both spectral and color Doppler. Therefore, the documentation must support the use of color flow and spectral Doppler.

However, if the documentation does not support the spectral or color Doppler information, you should look to 93307 (Echocardiography, transthoracic, real-time with image documentation, (2D), includes M-mode recording, when performed, complete, without spectral or color Doppler echocardiography).

Echocardiograms defined: Echocardiograms use high-frequency sound waves to create images of the heart. The cardiologist then uses the images to evaluate the heart's structure to see how well it is functioning.

How Does CERT Work? Find Out

During each reporting period, CERT chooses a stratified random sample of claims submitted to A/B Medicare administrative contractors (MACs) and Durable Medical Equipment MACs (DMACs) and requests that the provider and or the suppliers who submitted those claims provides the supporting medical documentation.

Then, an independent medical review contractor reviews these claims to see if they were correctly paid per Medicare coverage, coding, and billing requirements. The current medical review contractor is AdvanceMed, and the current statistical contractor is The Lewin Group, Inc.

Upon review, if AdvanceMed discovers that criteria was not met in those claims or if the provider didn't submit the proper medical documentation to sufficiently support the billed claim, the claim is identified as either a total or partial improper payment. The improper payment may be recouped for overpayments or reimbursed for underpayments, CMS says.

CMS calculates the results of this review, and this becomes the national, annual Medicare Fee-for-Service (FFS) improper payment rate. The Department of Health and Human Services (HHS) publishes these results in its agency financial report (AFR).

Why should this matter to you? This improper payment rate calculation is important because it measures the MACs performance and gives CMS insight into what caused the claim submission errors, according to a CMS fact sheet about Medicare claim review programs.

Don't miss: "The improper payment rate is not a 'fraud rate,' but is a measurement of payments that did not meet Medicare requirements," CMS says on its website. "The CERT program cannot label a claim fraudulent."

When CERT Comes Knocking, Make Sure to Answer

You can respond to a CERT request in several ways, according to Michael Hanna, MPA, CDME, provider outreach and education consultant at CGS-DME MAC Jurisdiction C in Nashville, Tennessee, in a recent webinar:

  • Fax - this is the preferred method, Hanna said. "Always include the barcode sheet as part of your fax package. This simply marries the documentation you're submitting with that particular date of service the CERT contractor has chosen for a review."
  • The electronic submission of medical documentation system (esMD). With this method, you use the gateway you contracted with and follow standard procedure.
  • Mail - "If it's a sizeable amount of documentation, or you've already saved it to a CD, you can mail it in," Hanna added.

Don't miss: You can make extension requests by telephone only.

Caution: Normally, the CERT contractor only grants extensions in extreme circumstances such as natural disasters like hurricanes, tornadoes, and ongoing fires, according to Hanna.

"But, if you are simply waiting on medical records from the physician, it is possible the CERT contractor may not grant that extension," Hanna said. "If that is the case, you should always send the CERT contractor what you have available, and then if they disagree or find something missing or not valid, you do have appeal rights."

Any claim errors the CERT contractor finds will result in a revised Medicare admittance advice where they will deny that claim and an overpayment demand where they ask you to recoup the money, Hanna cautioned.

Know Your Appeal Rights

As mentioned previously, you do have appeal rights when it comes to CERT. The MAC Novitas does a good job of identifying how this appeals process works.

The first level of appeal is called a "redetermination." You must submit your redetermination request in writing and file it within 120 days from the date on your RA (Remittance Advice) or MSN (Medicare Summary Notice).

You must include all of the following information with your appeal request, according to Novitas:

  • The patient's name
  • The patient's Medicare Beneficiary ID
  • The CERT identification (CID) number
  • The date CERT made its initial determination
  • The service or items you're requesting the redetermination for
  • The date of service
  • Both the printed name and signature of the person making the request.
  • The printed name and signature of the person making the request
  • An explanation of the requestor's relationship to the providing physician.

When you submit a redetermination request, you must also include any information that supports the coverage of the appealed service. And if the denial happened because you did not respond to an Additional Documentation Request (ADR) in time, then you must also include the information requested in the ADR, along with your appeal request.

Resource: To learn more about the CERT program, visit