CERT Audit Finds Insufficient Documentation Results in Improper Payments

Recent analysis by the Comprehensive Error Rate Testing (CERT) initiative of physical therapy claims revealed that insufficient documentation contributed to improper payments issued to providers.

The CERT is a Centers for Medicare & Medicaid Services initiative aimed at educating and monitoring the accuracy of FFS Medicare Administrative Contractors (MACs) payments made on submitted claims. While the primary goal is improving contractor performance by reducing improper payment rates, any provider claims selected for a CERT audit will be subject to potential postpayment denials, payment adjustments, or other actions depending on the result of the audit.

Insufficient documentation during a CERT audit means that the submitted medical documentation is inadequate to support payment for the services billed; the CERT contractor reviewers could not conclude that the billed services were actually provided, were provided at the level billed, and/or were medically necessary; or a specific documentation element that is required as a condition of payment was missing (for example, a physician signature on an order).

During the recent physical therapy claims audit the CERT contractor determined that the following areas of physical therapy documentation were insufficient and resulted in improper payments: (a) initial evaluation; (b) individualized plan of care, signed and dated; (c) updated signed and dated plan of care; (d) time spent for the therapy services; (e) electronic signature or legible signature of the performing provider on all notes.

More specifically, the CERT audit has found documentation deficiencies when providers fail to document in the initial evaluation a course of therapy through objective findings. Similarly, physical therapy records of individualized or updated plans of care have been flagged for insufficient documentation when they were missing one or more of the following items: the type, amount, frequency, and duration of the services to be furnished (or the notes failed to indicate the diagnoses and anticipated short and long-term goals; signature and/or date of the performing provider). The CERT audits have also determined that some providers’ fail to note the total treatment time (including the minutes for the timed code treatment and untimed code treatment). Finally, missing electronic or legible provider signature on medical notes have also been observed during CERT audits.

Any errors identified by a CERT audit can be appealed through the existing Medicare five-level appeal process. As with any appeal of an audit, providers wishing to preserve their position must appeal within a specific time frame.

If you have any questions regarding a CERT audit, the Medicare appeal process, enrollment, revalidation, revocation, exclusion or have other health law related inquiry, please contact our office.