News: CERT links $126.9 million in improper payments to insufficient documentation

CDI Strategies - Volume 12, Issue 32

CMS had a 71.3% improper payment rate for surgical dressings in 2017, accounting for 0.3% or $126 million of the overall Medicare Fee-for-Service (FFS) improper payment rate that year, according a Comprehensive Error Rate Test (CERT) report in the most recent Medicare Quarterly Provider Compliance Newsletter.

The July CERT report pulls numbers from 2017 Medicare FFS Supplemental Improper Payment Data, and lists insufficient documentation as the principal culprit , Revenue Cycle Advisor reported.

In some instances, the insufficient documentation was due to the lack of a valid physician or nurse practioner order, Medicare guidelines, and Medicare Administrative Contractor-specific guidelines. Such elements include a physician signature or date, the type of dressing, frequency of dressing change, and/or expected duration of need.

In other instances, according to the report, clinical documentation for a wound evaluation as required by a Local Coverage Determinant (LCD) was lacking. LCDs may require documentation of the type of wound, wound location, and/or amount of drainage.

Editor’s note: This article originally appeared in Revenue Cycle Advisor. To read the full CERT report, click here. To learn more about what CERT is, read this Q&A.

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