skip to content
Thank you for visiting First Coast Service Options' Medicare provider website. This website is intended exclusively for Medicare providers and health care industry professionals to find the latest Medicare news and information affecting the provider community.
To enable us to present you with customized content that focuses on your area of interest, please select your preferences below:
Select which best describes you:
Select your location:
Select your line of business:

By clicking Continue below you agree to the following:

LICENSE FOR USE OF "PHYSICIAN'S CURRENT PROCEDURAL TERMINOLOGY" (CPT), FOURTH EDITION End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2022 American Medical Association (AMA).

All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.
You, your employees, and agents are authorized to use CPT only as contained in the following authorized materials:
Local Coverage Determinations (LCDs),
Local Medical Review Policies (LMRPs),
Bulletins/Newsletters,
Program Memoranda and Billing Instructions,
Coverage and Coding Policies,
Program Integrity Bulletins and Information,
Educational/Training Materials,
Special mailings,
Fee Schedules;

internally within your organization within the United States for the sole use by yourself, employees and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare and Medicaid Services (CMS), formerly known as Health Care Financing Administration (HCFA). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA website. Applicable FARS/DFARS restrictions apply to government use.

AMA Disclaimer of Warranties and Liabilities CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this agreement.

CMS Disclaimer: The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

AMA - U.S. Government Rights

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a )June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

ADA CURRENT DENTAL TERMINOLOGY, (CDT)
End User/Point and Click Agreement: These materials contain Current Dental Terminology (CDTTM), Copyright © 2016 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING ON THE BUTTON LABELED "ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK ON THE BUTTON LABELED "DECLINE" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

Subject to the terms and conditions contained in this Agreement, you, your employees and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. License to use CDT for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the ADA website.

Applicable Federal Acquisition Regulation Clauses (FARS)\Department of restrictions apply to Government Use.

ADA DISCLAIMER OF WARRANTIES AND LIABILITIES: CDT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third party beneficiary to this Agreement.

CMS DISCLAIMER: The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT should be addressed to the ADA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

End Disclaimer


This website provides information and news about the Medicare program for health care professionals only. All communication and issues regarding your Medicare benefits are handled directly by Medicare and not through this website. For the most comprehensive experience, we encourage you to visit Medicare.gov or call 1-800-MEDICARE. In the event your provider fails to submit your Medicare claim, please view these resources for claim assistance.
Join eNews       En Español
Text Size:
YouTube LinkedIn Email Print
Close
Send a link to this page
[Multiple email addresses must be separated by a semicolon.]
Last Modified: 7/1/2025 Location: FL, PR, USVI Business: Part A

CERT Insider’s Guide – Part A Second Quarter 2025

Comprehensive Error Rate Testing (CERT) program background

The CERT program measures payment compliance with Medicare fee-for-service (FFS) program federal rules, regulations, requirements, and calculates an improper payment rate. CMS uses the CERT program to calculate a national improper payment rate as well as contractor and service specific improper payment rates using a stratified random sample of claims selected for review.

Fiscal year (FY) 2024 Medicare FFS estimated improper payment rate

The FY 2024 Medicare FFS estimated improper payment rate is 7.66%, representing $31.70 billion in improper payments. The table below outlines the improper payment rate and projected improper payment amount by claim type for FY 2024. The reporting period for this improper payment rate is for claims submitted July 1, 2022, through June 30, 2023.

Claim Type

Improper Payment Rate

Improper Payment Amount

Overall
7.66%
$31.70 B (Billion)
Inpatient rehabilitation facilities (IRFs): Defined as all services with a provider type of inpatient hospitals and inpatient rehab units
26.5%
$2.0 B

CERT claim reviews

The Cert Insider’s Guide provides proactive insight into CERT audit activities for the second quarter of 2025 prior to the finalization of the next CERT report. The following IRF claim denials contributed to the highest improper payment rates by service type for Part A.

CERT Finding
Resolution
Resource(s)
Pre-admission screening missing
A pre-admission screening serves as the basis for the initial determination of whether the patient meets the requirements for an IRF admission to be considered reasonable and necessary:
• Must be completed within 48 hours prior to admission
• Detailed documentation must justify the patient requires, will benefit from, and is able to actively participate in intensive rehabilitation therapy
• Conducted by a licensed or certified clinician or rehabilitation physician
CMS IOM Pub. 100-02, Medicare Benefit Policy, Chapter 1, section 110
Medicare Learning Network (MLN) Article: MM12353 – Internet Only Manual Updates to Publication (Pub.) 100-02 to Implement Updates to Policy and Correct Errors and Omissions (Inpatient Rehabilitation Facility (IRF))
Checklist: Inpatient Rehabilitation Facility (IRF) documentation
The documentation does not support that the beneficiary requires the active and ongoing therapeutic intervention of multiple therapy disciplines.
For an IRF stay to be reasonable and necessary, the beneficiary must require active and ongoing intervention of multiple therapy disciplines:
• Physical therapy (PT), occupational therapy (OT), speech language pathology (SLP), or prosthetics/orthotics, with at least one being PT or OT
CMS IOM Pub. 100-01 Medicare General Information, Eligibility, and Entitlement, Chapter 4, section 10.9
Medicare Learning Network (MLN) Article: MM12353 – Internet Only Manual Updates to Publication (Pub.) 100-02 to Implement Updates to Policy and Correct Errors and Omissions (Inpatient Rehabilitation Facility (IRF))
Checklist: Inpatient Rehabilitation Facility (IRF) documentation
The documentation does not support that the beneficiary can reasonably be expected to actively participate in, and benefit significantly from, the intensive rehabilitation therapy program.
One criterion for an IRF stay to be considered reasonable and necessary is an intensive rehabilitation therapy program is required:
• Generally accepted standard of care is 1-on-1 therapy, generally consisting of 3 hours per day, 5 days per week
• In certain well-documented cases, this intensive rehabilitation might consist of at least 15 hours of therapy within a 7 consecutive day period, beginning with the date of admission to the IRF
Required therapy treatment begins within 36 hours from midnight of the day of admission to the IRF:
• Group therapy is acceptable but may not constitute most of the therapy:
• Justification for the use of group therapies must be documented in the medical record
CMS IOM Pub. 100-02, Medicare Benefit Policy, Chapter 1, section 110
Checklist: Inpatient Rehabilitation Facility (IRF) documentation
Interdisciplinary team (IDT) meeting notes/records – Missing
IDT meetings must be led by a rehab physician either in person or remotely via a mode of communication such as video or telephone conferencing, who documents concurrence with all decisions made at each meeting:
• IDT meetings held at minimum of once a week:
• A week is 7 calendar days beginning with the admission day counting as day 1
• If a patient is admitted to an IRF on the day IDT meetings are scheduled, CMS expects all patients in the IRF to be discussed during that meeting
• CMS will permit IDT meetings to be completed by day 8 of a patient's stay in certain circumstances
CMS IOM Pub. 100-02, Medicare Benefit Policy, Chapter 1, section 110
Medicare Learning Network (MLN) Article: MM12353 – Internet Only Manual Updates to Publication (Pub.) 100-02 to Implement Updates to Policy and Correct Errors and Omissions (Inpatient Rehabilitation Facility (IRF))
Checklist: Inpatient Rehabilitation Facility (IRF) documentation
The documentation does not support a reasonable expectation that at the time of admission to the IRF the patient’s medical management and rehabilitation needs required an inpatient stay and close physician involvement - - plan of care (POC) missing
The overall POC is developed by the rehabilitation physician with input from the interdisciplinary team:
• Must completed within 4 days of the IRF admission
• Detailed information related to the patient’s medical prognosis and the anticipated interventions (PT, OT, SLP, and prosthetic/orthotic therapies), functional outcomes, and discharge destination from the IRF stay must be included
• Supports the medical necessity of the IRF admission
CMS IOM Pub. 100-02, Medicare Benefit Policy, Chapter 1, section 110
Medicare Learning Network (MLN) Article: MM12353 – Internet Only Manual Updates to Publication (Pub.) 100-02 to Implement Updates to Policy and Correct Errors and Omissions (Inpatient Rehabilitation Facility (IRF))
Checklist: Inpatient Rehabilitation Facility (IRF) documentation

IRF benefit

The inpatient rehabilitation facility (IRF) benefit is designed to provide intensive rehabilitation therapy in a resource intensive inpatient hospital environment for patients who, due to the complexity of their nursing, medical management, and rehabilitation needs, require and can reasonably be expected to benefit from an inpatient stay and an interdisciplinary team approach to the delivery of rehabilitation care.
The IRF benefit is not to be used as an alternative to completion of the full course of treatment in the referring hospital. A patient who has not yet completed the full course of treatment in the referring hospital is expected to remain in the referring hospital, with appropriate rehabilitative treatment provided, until such time as the patient has completed the full course of treatment. Though medical management can be performed in an IRF, patients must be able to actively participate in and benefit from the intensive rehabilitation therapy program provided in IRFs in order for an IRF claim to be considered reasonable and necessary, in accordance with 42 CFR § 412.622(a)(3)(ii) external link.
Therefore, patients who are not able to actively participate in and benefit from the intensive rehabilitation therapy services because they are still completing their course of treatment in the referring hospital should remain in the referring hospital until they are able to do so. Conversely, the IRF benefit is not appropriate for patients who have completed their full course of treatment in the referring hospital, but do not require intensive rehabilitation. Medicare benefits are available for such patients in a less-intensive setting.

Provider’s next steps

When a CERT claim is found to be in error, First Coast will have the claim adjusted and will process the overpayment or underpayment.
Providers will not receive a findings letter; however, a demand letter will be mailed to the billing address on file. If you would like to obtain the CERT denial rationale for the claim, contact First Coast and submit a request via email to QuestCERT2@fcso.com. Please do not include any protected health information (PHI) or personally identifiable information (PII), only the 7-digit claim identifier (CID) number is needed to check status or obtain the denial rationale.
If the billing provider disagrees with the CERT decision, they have 120 days from the date of the adjustment to file a level 1 appeal, known as a redetermination. The date of the adjustment can be found on the demand letter. Include any missing or additional documentation you may have to support the billed services with the appeal. Fill out the request for appeal thoroughly and ensure it is signed.

Educational Events

First Coast consistently offers live and on-demand educational opportunities to support our providers in achieving Medicare compliance. Visit the events calendar to view upcoming webinars and the On-Demand Learning to view webinar recordings and click-and-play videos.

Resources

• CERT external link
• CERT resources center
• Appeals webpage
• Medicare Learning Network (MLN) – MLN4824456 Inpatient Rehabilitation Hospitals & Inpatient Rehabilitation Units external link
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.