CERT Insider’s Guide – Part A 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 A.
Inpatient hospital
| CERT Finding | Resolution | Resource(s) |
|---|---|---|
| Psychiatric evaluation missing | Medical records must stress the psychiatric components of the record, including history of findings and treatment provided for the psychiatric condition for which the patient is hospitalized. |
CMS IOM Pub. 100-02 Medicare Benefit Policy Manual, Chapter 2, section 30
|
| Psychiatric certification or recertification inadequate |
At the time of admission or as soon thereafter, the admitting physician or a medical staff member with knowledge of the case, must certify the medical necessity for inpatient psychiatric hospital services. The first recertification is required by the 12th day of hospitalization. Subsequent recertifications are required no less than every 30 days. In the initial certification and subsequent recertification, the physician must provide documentation confirming that the admission to the inpatient psychiatric facility was medically necessary for one of two reasons: either for treatment that is likely to enhance the patient's condition or for the purpose of conducting a diagnostic study. Recertifications must also satisfy all the following requirements: The hospital records indicate the services furnished were either intensive treatment services, related services necessary for diagnostic study at admission, or equivalent services. Physicians required to recertify that the patient continues to need, daily, active treatment furnished directly by or requiring the supervision of inpatient psychiatric facility personnel. |
|
Diagnosis related group (DRG)
| CERT Finding | Resolution | Resource(s) |
|---|---|---|
| Clinical presentation, prognosis and expected treatment did not support the expectation of the need for hospital care spanning two or more midnights | The two-midnight presumption outlined in CMS-1599-F specifies hospital stays spanning two or more midnights after the beneficiary is formally admitted as an inpatient will be presumed to be reasonable and necessary for the inpatient status as long as the hospital stay is medically necessary. The clinical presentation, prognosis and expected treatment in the medical documentation should support the expectation of the need for hospital care spanning two or more midnights. |
42 Code of Federal Regulations (CFR) 412 and 424 CMS IOM Pub. 100-08 Medicare Program Integrity Manual, Chapter 6, section 6.5 |
| Discharge status incorrectly coded |
The discharge status code identifies where the patient is being discharged to at the end of their facility stay or transferred to such as an acute/post-acute facility. The discharging facility should ensure that documentation in the patient’s medical record supports the billed discharge status code. Billing the incorrect code may affect their payment, but will impact any other facility receiving the patient, often preventing them from successfully submitting their claim to Medicare. Facilities are encouraged to follow-up with the patient after discharge and prior to submitting the claim to Medicare to ensure the patient went to the planned facility that was recorded in the medical record. This will prevent incorrect billing of the discharge status code and avoid unnecessary adjustments to claims when the incorrect code is used. |
CMS fact sheet: Patient Discharge Status Codes Matter
|
| Preoperative surgeon's office notes were missing - Transcatheter Aortic Valve Replacement (TAVR) |
TAVR is covered for the treatment of symptomatic aortic valve stenosis. The patient (preoperatively and postoperatively) is under the care of a heart team: a cohesive, multi-disciplinary, team of medical professionals. The heart team concept embodies collaboration and dedication across medical specialties to offer optimal patient-centered care. The heart team includes the following:
The joint care from the heart team must be documented int eh medical record and available when requested for medical review. |
National Coverage Determination (NCD) TAVR (20.32) Article: Transcatheter aortic valve replacement Transcatheter Aortic Valve Replacement
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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