Comprehensive Error Rate Testing
Common CERT Errors - Podiatry
In upcoming Communiqué articles, we will be focusing 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 podiatry.
Analysis of our current CERT error findings show that the most common errors assessed for this specialty involve insufficient documentation of nail debridement services or incorrect coding issues based on documentation. Below is a sample of the services involved and the CERT reviewer's comments listed below.
Insufficient Documentation
11041 - Debridement; skin, full thickness.
11721 - Debridement of nail(s) by any method(s); six or more.
CERT Comment: Insufficient documentation submitted for review to support skin debridement of left foot great toe, right foot great toe, right foot third digit, and nail debridement of 6 or more nails. Submitted documentation states, "Ulcer care and nail DB this visit."
11721 - Debridement of nail(s) by any method(s); six or more.
CERT Comment: Need documentation that nails were debrided on date of service billed. Office note sent does not mention treatment rendered. No additional documentation submitted.
73630 - Radiologic examination, foot; complete, minimum of three views.
CERT Comment: The office note states that the plan of treatment includes and x-ray of the left foot but no results to verify that the x-rays were taken are included.
Service Incorrectly Coded
11721 - Debridement of nail(s) by any method(s); six or more.
CERT Comment: Submitted office visit notes that document debridement of a corn and plantar aspect of the 5th toe only. Documentation supports 11720; debridement of nail(s) by any method; one to five.
CERT Comment: Documentation submitted included physician progress notes for billed date of service which indicates, "O: Nails are thick, brittle, and have yellow discoloration." "P: Debridement abnormal nail tissue." No notation of number of nails treated or bilateral service. Documentation supports down code from 11721 to 11720 for one to five nails.
99262 - Follow-up inpatient consultation for an established 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 Comment: Provider billed multiple inpatient consultations. Per CPT 2004, MCM 15068, 95/97 E/M guidelines - "If the physician consultant has initiated treatment at the initial consult and participates thereafter in the patient's management the codes for subsequent hospital care should be used." Documentation supports change of code from 99262 to 99231 with problem focused Hx and Ex, and low complexity MDM.
Insufficient documentation of services and incorrect coding based on documentation submitted, 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.
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. It is also important to verify that the records are legible, that they clearly identify the patient, and that the signature of the rendering provider is included.
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.
