News: MLN releases fact sheet on CERT program documentation requirements

CDI Strategies - Volume 18, Issue 27

The Medicare Learning Network (MLN) recently released a fact sheet for the CMS’ Comprehensive Error Rate Testing (CERT) program, according to JustCoding.

According to MLN, the CERT program is designed to “measure improper payments” in the Medicare Fee-for-Service (FFS) program by reviewing a “random sample” of Medicare FFS claims. “Once the CERT program identifies a claim in the sample,” the MLN explained, “it requests (via fax, letter, or phone call) the associated medical records and other related documentation from the provider or supplier who submitted the claim.”

In order for CERT to affirm and pay for necessary services, the patient’s medical record must demonstrate that the services or procedures provided were medically necessary. Among the types of documentation that may be used for this purpose, the MLN instructed, are as follows:

  • A signed office note from a previous visit where the provider ordered a diagnostic or other service
  • The care plan written by the supervising physician who bills for an “incident to” service
  • For incident to services, the care plan written by the supervising physician or non-physician practitioner
  • Lab orders for recurring tests to meet the specific needs of an individual patient

The MLN also issued guidance with respect to common documentation errors—ones that, if present, would invalidate reimbursement.

For example, incomplete progress notes (e.g., unsigned, undated, insufficient detail), unauthenticated medical records (e.g., no provider signature, no supervising signature, illegible signatures, electronic signatures without an attached protocol or policy delineating the process for such signatures), and no documentation of intent to order services and procedures (e.g., incomplete or missing signed orders)—all of these, if found in the submitted medical documentation, would render documentation “insufficient to support [a] Medicare payment for the services billed.”

The MLN fact sheet also contains information regarding specific types of services procedures relating to:

  • Vertebral augmentation procedures
  • Evaluation and Management services
  • Computed tomography

Editor’s note: To read the JustCoding coverage, click here. To read the MLN fact sheet, click here.

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