CERT Error Update - Insufficient Documentation

Home Provider Part B Publications

The November 2005 CERT Report reflected a substantial decrease in errors assessed for non response to CERT medical records requests. However, we continue to see a large portion of our error rate attributed to insufficient documentation of services. These errors continue to have a significant impact on our error rate as a carrier, and at a national level.

For claims sampled for the upcoming May 2006 CERT report (submitted 10/01/04-09/30/05), our analysis shows that errors for insufficient documentation accounted for 33% of the total claim detail line errors received. It is our goal to increase awareness of the specific reasons for these errors and subsequently reduce the instances of insufficient documentation.

For the above reporting period, four Berenson-Eggers Type of Service (BETOS) categories accounted for 42% of the total errors assessed for insufficient documentation. Below is summary of the top error categories and the documentation issues associated with these errors.

TOS (BETOS) Category	Detail Line Errors	Documentation Issues
Hospital visit - subsequent	14	Progress notes submitted do not include all dates of service billed Additional documentation submitted is lab report, consultation and admit and discharge summaries. Missing progress note for subsequent hospital visit Documentation supports that service was provided by different physician than claim was billed under Treatment order submitted does not support hospital visit billed Need typed legible copy of MD progress notes
Chiropractic	12	Documentation fails LCD requirements (CHIRO-001) for subsequent visit. There is no review of chief complaint, exam, or evaluation of treatment effectiveness Missing required treatment plan and documentation for preceding 6 months of services as requested Documentation does not include required treatment plan, initial evaluation, or evidence to support an acute episode Documentation is missing indication of the areas that were manipulated for services billed for 3-4 regions
Office visit - established	9	Wrong date of service billed No documentation of face to face encounter with exchange of clinically relevant information to support separate E/M service (99211) billed with injection Received lab report only. No documentation of E/M visit billed
Nursing home visit	9	Submitted documentation for different date of service than requested Provider indicated that the wrong date of service was billed Submitted were lab reports, med sheets, orders and ancillary notes. No documentation for nursing facility service billed

When the CERT Contractor receives initial documentation in response to a request letter, but it is still missing key elements, a follow-up letter or call is initiated. Providers then have an additional 15 days to submit the requested documentation. The CERT follow-up letter describes specifically what additional documentation is needed to support the billed services. However, in many instances, duplicate documentation is submitted in response to the follow up contact. In these cases, CERT closes their review and an insufficient documentation error is assessed. Contractors are then required to request a refund of the Medicare payment for the undocumented services.

In our follow-up contacts for these claims, we are often able to obtain the additional documentation on behalf of the CERT Contractor. However, our goal is to eliminate the need for multiple follow-up contacts to obtain records that were available and should have been provided directly to the CERT Contractor.

If your facility receives a CERT request for medical records, please review the services billed on the sampled claim in order to ensure that documentation for all services is present, prior to forwarding to the CERT contractor. This includes any treatment plans, physician orders, lab reports and face-to-face evaluation and management service notes. It is also extremely important to verify that the records are legible and that they clearly identify the patient and the rendering provider. If a follow-up request is received for additional information, please verify that you are responding with the information that is specified.

If you have questions regarding what documentation is needed to fully comply with the CERT record request, you may contact the CERT Contractor at 301-957-2380. For more information regarding the CERT record request process and sample letters, please visit the CERT Documentation Contractor provider website at http://www.certcdc.com/certproviderportal/default.aspx