CERT Insider's Guide - Part B Fourth 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) |
|
End Stage Renal Disease (ESRD) Services: Dialysis |
21.6% |
$159 M (million) |
|
Psychiatric services |
16.1%
|
$254 M (million) |
CERT claim reviews
The CERT Insider's Guide provides proactive insight into CERT audit activities for the fourth quarter of 2025 prior to the finalization of the next CERT report. The following services contributed to the highest improper payment rates by service type for Part B.
ESRD Service: Dialysis
|
CERT finding |
Resolution |
Resource(s) |
|---|---|---|
|
Insufficient documentation:
|
Physicians and practitioners managing center-based patients on dialysis are paid a monthly rate for most outpatient dialysis-related physician services furnished to a Medicare ESRD beneficiary. The payment amount varies based on the number of visits provided within each month and the age of the ESRD beneficiary. Under this methodology, separate codes are billed for providing one visit per month, two to three visits per month and four or more visits per month. The lowest payment amount applies when a physician provides one visit per month; a higher payment is provided for two to three visits per month. To receive the highest payment amount, a physician or practitioner would have to provide at least four ESRD-related visits per month. Clinical documentation must support the face-to-face encounters between the treating physician/NPP and the beneficiary during dialysis treatment for the month of dialysis. Report the appropriate code for providing one visit per month, two to three, or four or more visits per month. |
CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 8 LCD, 37564 - Frequency of Hemodialysis |
|
Insufficient documentation:
|
Treatment orders must include dialysis prescription, exchange frequency and dwell time |
CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 8 LCD, 37564 - Frequency of Hemodialysis |
Psychiatry Services
|
CERT finding |
Resolution |
Resource(s) |
|---|---|---|
|
Insufficient documentation:
|
Medical records must support treating provider's order for or clinical documentation to support the plan/intent to order diagnostic testing.
|
CMS IOM Pub. 100-02, Benefit Policy Manual, Chapter 15, section 80 Physician Ordering Laboratory Tests: Your Vital Role in Submitting Documentation LCD, L33252 - Psychiatric Diagnostic Evaluation and Psychotherapy Services LCA, A57520 - Billing and Coding: Psychiatric Diagnostic Evaluation and Psychotherapy Services |
|
Missing documentation:
|
The medical record must indicate length of time spent in the psychotherapy encounter.
|
CMS IOM Pub. 100-02, Benefit Policy Manual, Chapter 15, section 80 LCD, L33252 - Psychiatric Diagnostic Evaluation and Psychotherapy Services LCA, A57520 - Billing and Coding: Psychiatric Diagnostic Evaluation and Psychotherapy Services |
|
Incorrect coding:
|
The medical record documentation must clearly demonstrate the session start and stop times and/or total time spent providing services to the beneficiary. |
CMS IOM Pub. 100-02, Benefit Policy Manual, Chapter 15, section 80 LCD, L33252 - Psychiatric Diagnostic Evaluation and Psychotherapy Services LCA, A57520 - Billing and Coding: Psychiatric Diagnostic Evaluation and Psychotherapy Services |
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.
References