WPS Commitment to Error Rate Reductions

The Centers for Medicare & Medicaid Services (CMS) implemented the Comprehensive Error Rate Testing (CERT) program to measure and recover improper payments in the Medicare fee-for-service (FFS) program. CMS utilizes CERT review results to calculate national Medicare fee-for-service error rates. Medicare contractors are required to implement aggressive efforts to lower these error rates by developing plans that address the cause of the errors and outline efforts for correction of these issues.

As the Medicare contractor in this jurisdiction, it is our responsibility to ensure that Medicare claims are submitted and processed correctly. Through close monitoring, we have identified the following areas of concern for Part B.

  • Evaluation and Management (E/M) Issues
    • Documentation must support the level of service billed. Currently claims are being recoded because the level billed is not adequately supported in the documentation.
    • Documentation for inpatient hospital care must support that a face-to-face visit occurred. You cannot bill for E/M if you do not see the patient. Example: Reviewing the patient's chart and writing an order cannot take the place of a face-to-face encounter.
  • Chiropractic Service Issues
    • Improper billing of the "AT" modifier for chiropractic services that are documented as maintenance therapy, or lack of a documented plan of care.
  • Diagnostic Service Issues
    • Missing signed physician order or progress note showing intent for performance of diagnostic services (ex. laboratory, radiology services)
  • Therapy Issues
    • Missing documentation of physician involvement in patient care (ex., treatment plan) and missing documentation of time actually spent in the delivery of the modality

What Should You Do If You Receive a CERT Error?

It is crucial that providers in our jurisdictions comply with CERT requests for medical records in a timely manner and submit documentation that supports all services billed to Medicare, including the level of care and medical necessity. We encourage all providers to perform a self-audit on your medical record documentation to ensure completeness. We also encourage you to examine your billing practices. If you utilize a billing service, we recommend sharing educational information to assist with the preparation and submission of your Medicare claims.

  • To request additional education or to submit questions regarding your specific CERT findings, please e-mail us at medicareadmin@wpsic.com. Enter "CERT Question" and the CERT Claim ID (CID) number in the subject line, and include your provider number in the body of the email. Do not include sensitive information such as your patient's Medicare Health Insurance Claim (HIC) number in your email.

To review the latest CMS CERT Reports and Provider information, please visit the CMS CERT website(external link)

Page Last Updated: Wednesday, 05-Oct-2011 13:56:10 CDT