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CERT Insider's Guide - Part B 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, and requirements and calculate 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)
General surgery 4.8% $54.4 M (Million)
Diagnostic radiology 7.2% $264 M

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 services represent the highest improper payment rates by service type for Part B. 

Surgery

CERT Finding Resolution Resource(s)

Insufficient documentation. Missing order / intent to order

 

Medical records must support treating provider's order for nail care performed in a skilled nursing facility to support debridement of nail(s) by any method(s); six or more. 

  • The order must be dated and must have been issued by the supervising physician prior to mycotic nail debridement services being rendered.
  • Telephone or verbal orders not written personally by the supervising physician must be authenticated by the dated physician’s signature within a reasonable period of time following issuance of the order.
  • The order must be consistent with the attending physician’s overall plan of care.
  • The order must be for medically necessary services to address a specific patient complaint of physical finding.
  • Routinely issued or “standing” facility orders for mycotic nail debridement services that do not meet the above requirements are insufficient.
  • Services to residents of nursing homes performed at the request of the patient or patient’s family / conservator should indicate if the request was from the patient or the patient’s family/conservator.
    • When the request is from someone other than the patient, the documentation should identify the requesting person's relationship to the patient.

LCD: Nail Debridement (L33922) 

Billing and Coding: Nail Debridement (A57672)

Checklist: Surgical services: Nail cutting/paring and debridement
Insufficient documentation 

Medical records must support the neurostimulator implantation services were provided.

  • Indicate if request is for a trial or permanent placement.
  • Physician office notes including:
    • Condition requiring procedure
    • Physical evaluation
    • Treatments tried and failed including but are not limited to:
      • Spine surgery
      • Physical therapy
      • Medications
      • Injections
      • Psychological therapy
      • Documentation of appropriate psychological evaluation
  • For permanent placement, include the above documentation, as well as documentation of pain relief with the temporary implanted electrode(s).
  • A successful trial should be associated with at least 50% reduction of target pain or 50% reduction of analgesic medications.

CMS IOM Pub. 100-08 Medicare Program Integrity Manual, Chapter 3 

Implantation of Spinal Neurostimulator

NCD: Electrical Nerve Stimulators (160.7)
Insufficient documentation 

Medical record documentation to support the medical necessity for cataract removal. 

Cataract surgery will be considered medically reasonable and necessary when one or more of the following indications are present:

  • Visual function no longer meets the patient’s needs based on visual acuity, visual impairment, and potential for functional benefits.
  • Visual Impairment and function are not correctable by glasses or other non-surgical measures.

The patient has undergone a preoperative examination that documents the following:

  • Inability to function satisfactorily due to visual impairment while performing various activities of daily living.
  • Confirmation that cataract is causing the visual impairment or other ocular or systemic conditions.
  • Cataract is causing unacceptable glare, polyopia, or reduced quality of vision.
  • There is clinically significant anisometropia in the presence of a cataract.
  • The lens opacity interferes with optimal diagnosis or management of posterior segment conditions.
  • The lens causes inflammation or secondary glaucoma (phacolysis, phaco-anaphylaxis).
  • There is worsening angle closure (phacomorphic glaucoma) due to increase in size of the crystalline lens.

A significant cataract is present in a patient who will be undergoing concurrent surgery in the same eye, such as a trabeculectomy or a corneal transplant when the surgeon deems that the decreased morbidity of single stage surgery is of significant benefit over surgery on separate dates.

CMS IOM Pub. 100-08 Medicare Program Integrity Manual, Chapter 3 

CMS IOM Pub. 100-02 Medicare Benefit Policy Manual, Chapter 15, section 80 

LCD: Cataract Extraction (including Complex Cataract Surgery) (L38926) 

Billing and Coding: Cataract Extraction (including Complex Cataract Surgery) (A58592) 

Checklist: Cataract extraction

Diagnostic radiology

CERT Finding Resolution Resource(s)
Documentation to support medical necessity is inadequate. Medical record documentation must include medical necessity for the billed radiology exam.

CMS IOM Pub. 100-08 Medicare Program Integrity Manual, Chapter 3 

Checklist: Diagnostic radiology

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 

Checklist: Diagnostic radiology

Provider's next steps

When a CERT claim is found to be in error, Novitas 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 On-Demand Learning to view webinar recordings and click-and-play videos.

 

References