Comprehensive Error Rate Testing (CERT) Documentation Pointers
- Medicare expects the documentation to be generated during the time of service or shortly thereafter.
- Delayed entries within a reasonable time frame (24 hrs.) are acceptable for purposes of clarification, error correction, the addition of information not initially available, and if certain unusual circumstances prevented the generation of the note at the time of service.
- The medical record may not be altered. Errors must be legibly corrected so that the reviewer can draw an inference as to their origin. Deletions should have only a single thin line drawn through the deletion. These corrections, deletions or additions must be dated and legibly signed or initialed.
- Every note stands alone, i.e., the services performed must be documented at the outset.
- Delayed written explanations will be considered for purposes of clarification only. They cannot be used to add and authenticate services billed and not documented at the time of service or to retrospectively substantiate medical necessity. For that, the medical record must stand on its own with the original entry corroborating that the service was rendered and was medically necessary.
- All entries must be legible to another reader to a degree that a meaningful review can be conducted. Recommendation is made that only JCAHO approved abbreviations be used to prevent patient care errors and allow for proper review by subsequent readers. Illegible notes will not be used in determining medical necessity of a claim.
- All notes shall contain the patient's name and be dated and signed by the author.
- If the signature is not legible and does not identify the author, a printed version should be also recorded.