CERT (Comprehensive Error Rate Testing) Tips
In the world of Medicare it is critical for providers to have clear, accurate and complete medical documentation. Medicare has specific guidelines when it comes to documentation, and the CERT Contractor must follow these rules whenever they review documentation.
Unfortunately, on many occasions, CERT finds the documentation received does not support the procedures being billed. Sometimes, it is something as simple as legibility of the writing or incomplete notes. On other occasions, the documentation issue may involve "cookie cutter" templates where the patient complaints, physician notes documented procedures, and the medical findings are identical for the majority of beneficiaries. It is the responsibility of the provider to ensure services billed to the Medicare program are accurate and represent the individual care given to the patient.
Medical documentation needs to be unique, specific, and should accurately reflect the services being billed. The services billed should:
- Be individualized to the presenting problem(s) on the date in question
- Be clearly recorded and inclusive
- Be specific when it comes to the services provided.
Example: If you gave an injection, is there a clear order for it in the record? What was the medication and how much was injected? How was the medication administered? Where was it administered? Who administered the medication?
Remember to keep in mind:
- If your notes are handwritten, make sure they are legible. If the reviewer can't decipher the documentation, the service may not be allowed.
- If you perform a test, the order should be noted somewhere in the medical record.
- Include patient history documents to help substantiate services.
- When billing for timed codes, note the actual time in the chart and make certain your documentation clearly reflects the time you spent.