Comprehensive Error Rate Testing
CERT Error Focus - Subsequent Hospital Visits - CPT 99231-99233
In recent Communiqué articles, we have focused on CERT errors received by specific provider specialties. In our continuing effort to increase the awareness of all Medicare providers regarding documentation issues found as a result of CERT reviews, we have now begun to focus on specific services that contribute to our CERT error rate. Our focus this month is on insufficient documentation issues related to subsequent hospital visits, CPT procedure codes 99231-99233.
Analysis of our recent CERT error findings show that these services account for a large portion of our errors for insufficient documentation. In the majority of these cases, the provider has submitted documentation other than what the CERT contractor requested. CERT reviewer comments indicate that oftentimes an admission report, consultation note, discharge summary, etc., is submitted, rather than the requested subsequent hospital visit progress note(s). Furthermore, when CERT makes a follow-up contact for the missing documentation, they often receive the same documentation that providers submitted initially or the provider refers the CERT contractor to the hospital to obtain the additional information. At this point, the CERT contractor assesses an error for insufficient documentation, and the contractor is required to request a refund of the undocumented service(s).
Providers should be aware that, as stated in the CERT medical record request letter, "It is your responsibility to obtain additional supporting documentation from a third party (hospital, nursing home, etc.) as necessary." In our own follow-up contacts office medical record staff often initially explain the records are not onsite and therefore they are not responsible for obtaining them. In most cases, further explanation of the documentation requirements results in the office staff facilitating the retrieval of the records from the facility. However, there are also cases in which we must make an additional contact with management staff or a compliance officer in order to initiate this process.
Proper documentation of services billed to Medicare is vital in order to meet CMS' error rate reduction expectations, and WPS continues to identify problem areas contributing most significantly to our jurisdiction's error rate. Continued cooperation from providers in educating staff on the CERT program, and the importance of complying with CERT medical record requests is essential in order to reach these goals.
For more information regarding the CERT program and other issues related to CERT review findings, please visit our website.
If you have questions related to the CERT process or a specific CERT sampled claim, you may email us at
medicareadmin@wpsic.com
Be sure to include "CERT Question" in the subject line. Please also include your full name, telephone number, and Provider Identification Number (if available) in the body of the e-mail. This will assure a prompt and accurate reply to your question.
When e-mailing WPS Medicare, please do not include sensitive information. If your question pertains to a specific claim, include the Internal Control Number, not your patient's Medicare Health Insurance Claim Number.
