Comprehensive Error Rate Testing
Common CERT Errors - Nephrology
In recent Communiqué articles, we focused on CERT errors received by specific provider specialties. This will allow us to identify documentation needs and inadequacies and the impact that these specialties have on our CERT error rate. Our focus this month is on Nephrology.
Analysis of our current CERT error findings show that the most common errors assessed for this specialty involve insufficient documentation and/or no documentation. Below is a sample of the services involved, and the corresponding CERT reviewer's comments.
Insufficient Documentation
99233 - Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a detailed interval history -- a detailed examination -- medical decision making of high complexity.
90935 - Hemodialysis procedure with single physician evaluation.
CERT Comments:
- No inpatient progress note to support the hemodialysis procedure with MD evaluation or the evaluation and management service billed. Documentation submitted is partial hospital record that includes History and Physical, consult notes, discharge summary, and radiology and lab reports.
G0317 - End stage renal disease (ESRD) related services during the course of treatment, for patients 20 years of age and over; with 4 or more face-to-face physician visits per month
CERT Comments:
- Need documentation of four MD visits for ESRD related services, monthly care plan note, and standing orders for March 2004. Received progress notes signed by RN, and MD order sheet with dates highlighted for telephone and verbal orders. Unable to determine billing provider or member of group rendering service as billed.
No Documentation
90921- End stage renal disease (ESRD) related services per full month; for patients twenty years of age and over
99232- Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: an expanded problem focused interval history -- an expanded problem focused examination -- medical decision making of moderate complexity.
CERT Comments:
- Received note from provider stating "unable to process your request because no records are available for the date of service requested."
Insufficient documentation of services and lack of documentation continue to be areas of concern due to their impact on our CERT error rate. As a result of our follow-up calls to obtain outstanding CERT documentation from providers, we have often found that the patient's file is missing the documentation to support all services billed or the medical record staff is unaware of where the proper documentation is located.
Please be aware that services billed to Medicare Part B must be documented as billed in the medical records. Without adequate documentation, the services will be considered non-rendered, or not provided at the level at which they were billed.
If your facility receives a CERT request for medical records, please review the services billed in order to ensure that documentation for all services is present, prior to forwarding to the CERT contractor. This includes all care plans, physician orders, and face-to-face evaluation and management service notes which may be included in the procedure code(s) billed. It is also important to verify that the records are legible and that they clearly identify the patient.
If you have questions regarding what documentation is needed to fully comply with the CERT record request, you may contact the CERT Contractor at the number indicated on the request letter.
