CERT Insider's Guide – Part B First 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) |
| Part A providers [excluding hospital inpatient prospective payment system (IPPS)] | 7.56% | $14.19 B |
| Part B providers | 10.35% | $11.45 B |
| Hospital IPPS | 3.89% | $5.17 B |
CERT claim reviews
The CERT Insider's Guide provides proactive insight into CERT audit activities for the first quarter of 2025 prior to the finalization of the next CERT report. The following services represent the highest improper payment rates by service type for Part B.
Laboratory
| CERT Finding | Resolution | Resource(s) |
|---|---|---|
|
Insufficient documentation. Missing order/intent to order.
|
Medical records must support treating provider's order for or clinical documentation to support the plan/intent to order diagnostic testing.
|
42 Code of Federal Regulations (CFR) 424.5 CMS IOM Pub. 100-02, Benefit Policy Manual, Chapter 15, section 80 Checklist: Clinical labs
|
| Insufficient documentation. Missing test result. | Medical records must document the ordered testing results. |
CMS IOM Pub. 100-02, Benefit Policy Manual, Chapter 15, section 80 Checklist: Clinical labs
|
| Insufficient documentation. Missing risk assessment for urine drug screening. | Medical record documentation to support the medical necessity for the billed definitive urine diagnostic testing (UDT) must include beneficiary history, treatment plan and risk assessment. |
CMS IOM Pub. 100-08 Medicare Program Integrity Manual, Chapter 3 LCD: L36393 Controlled Substance Monitoring and Drugs of Abuse Testing Checklist: Clinical labs
|
Cardiology
| CERT Finding | Resolution | Resource(s) |
|---|---|---|
| Documentation to support medical necessity is inadequate. | Medical record documentation must include referring provider clinical documentation to support medical necessity for the transthoracic echocardiogram billed. |
CMS IOM Pub. 100-02 Medicare Benefit Policy Manual, Chapter 15, section 80.6
|
|
Insufficient documentation. Missing order.
|
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 |
Physical Therapy
| CERT Finding | Resolution | Resource(s) |
|---|---|---|
| Physical/Occupational/Speech Therapy certification/recertification - missing. |
Medicare states certification of the plan of care requires a dated signature on the plan of care, or some other document, by the physician or non-physician practitioner who is the primary care provider for the patient. In the absence of a formal certification document, a physician's progress note indicating the physician's agreement with the plan of care is acceptable. The certification of the plan of care should occur as soon as possible after it is established or within 30 calendar days of the initial therapy treatment. Payment may be denied if the physician does not certify the plan of care. The therapist should forward the plan to the physician as soon as it is established. Recertification of the plan of care, which also requires a physician or non-physician signature and date, should occur whenever there is a significant change in the plan or every 90 days from the initial plan of care certification. Verbal orders for certification or recertification of the plan of care must be signed and dated by the physician/non-physician practitioner within 14 calendar days.
|
CMS IOM Pub. 100-02, Benefit Policy Manual, Chapter 15, section 220 CMS IOM Pub. 100-04, Claims Processing Manual, Chapter 5, Section 20 |
| Documentation to support the services were provided or other documentation required for payment of the code inadequate. | Documentation should reflect the level of service reported on the Medicare claim. Mistakes continue with providers over coding and under coding patient visits. | Documentation checklists |
| Required progress report, performed at least once every 10 treatment days missing. |
Functional reporting using the G-codes and corresponding severity modifiers is required reporting on specified therapy claims. Specifically, they are required on claims: At the outset of a therapy episode of care (i.e., on the claim for the date of service (DOS) of the initial therapy service) At least once every 10 treatment days, which corresponds with the progress reporting period |
CMS IOM Publication 100-04, Claims Processing Manual, Chapter 5, section 10.6 |
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