June 25, 2009
CERT (Comprehensive Error Rate Testing): Insufficient Documentation & Medical Necessity Errors
The Comprehensive Error Rate Testing (CERT) program was designed by the Centers for Medicare & Medicaid Services (CMS) to randomly sample claims processed by Medicare Contractors to determine a national paid claims error rate. Recently CIGNA Government Services has noticed an increase in the number of insufficient documentation and medical necessity errors received as a result of CERT claim reviews.
This increase in the number of insufficient documentation and medically unnecessary claims seems to correlate with the regulations in the Medicare Benefit Policy Manual, Chapter 15, Section 80.6.1. This regulation states that while a physician order for a diagnostic test is not required to be signed, the physician must clearly document in the medical record his or her intent that the test(s) be performed. Therefore, we would advise the following:
Facilities:
- Keep ALL copies of paper or telephone orders in the patient's record as supporting documentation.
- If orders are unsigned, provide the full name and phone number of the provider who ordered the services.
Providers:
- All services rendered or ordered must be documented either in SIGNED office notes or as a part of a SIGNED order for a specific test.
- Signatures MUST be legible
- If the doctor's signature is illegible, the doctor's name should be printed , then signed with his/her name, and/or initials
Your cooperation with these documentation requirements will help us pay you correctly for the services you render to Medicare beneficiaries.
