Last Modified: 3/19/2019
Location: FL, PR, USVI
Business: Part A, Part B
The Centers for Medicare & Medicaid Services (CMS) implemented the Comprehensive Error Rate Testing (CERT) program to measure improper payments in the Medicare fee-for-service (FFS) program. CERT selects a random sampling of claim types, including clinical laboratory services, to request and review medical documentation to determine if the services were paid appropriately. If the criteria for coverage are not met or the provider fails to submit medical documentation to support the claim, the payment is recouped from the provider and an error is assessed to the contractor for that paid claim. First Coast is receiving errors for clinical laboratory services at both the national and contractor level in the CERT program.
Clinical laboratory tests had a national improper payment rate of 39 percent during the 2015 reporting period for the CERT program. Insufficient documentation caused more than 97 percent of the CERT review contractor identified improper payments. Insufficient documentation could be a missing order and/or documentation that support the intent to order the laboratory test(s), which are the highest errors in this category.
If you receive a documentation request from a Medicare review contactor, you will need, at a minimum, to check for the following in your documentation and submit it to the requesting review contractor:
• Procure all pertinent documentation from the ordering provider, if necessary, and ensure all documentation (including the order) is authenticated according to Medicare requirements
• If the documentation is not authenticated in compliance with Medicare’s legibility rules, obtain a signature attestation, signature log or any other documentation to authenticate the ordering provider
• Confirm authenticated order or documentation showing intent to order is submitted
• If you cannot provide a copy of the order, contact the ordering practitioner and request that they send you a copy of the order
• If the ordering practitioner cannot provide a copy of the order, request they send the progress notes, plan of care or another medical record entry prior to the lab tests, such as medical history or physical examination, documenting the intent to order the test(s) or why the test is needed
• Audit documentation prior to submission to ensure all requirements are met and requested documents are included in response
• Certify the documentation submitted supports medical necessity for services billed
• Refer to all available local coverage determinations (LCDs) for guidance on services being rendered and billed
Note: A best practice suggestion was received from a Florida laboratory. Their suggestion is to include information to support medical necessity for tests in the remarks section of the requisition or order that is received by the laboratory from the ordering/referring provider. This suggestion may not be sufficient in supplying medical necessity for all laboratory tests. Please review medical necessity guidelines for the laboratory test being rendered to evaluate the effectiveness of this suggestion.
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