tci Medicare Compliance & Reimbursement - 2015 Issue 3
Compliance: Avoid These Costly CERT Errors
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Article Overview
This article reviews CMS Comprehensive Error Rate Testing findings and highlights broad problem areas seen in Medicare Part B claims, including evaluation and management services, musculoskeletal procedures, chiropractic services, and major joint replacement cases. It is aimed at coders, billers, compliance staff, and clinicians who want to understand where documentation and claim review problems most often occur and why these issues can trigger payment errors, refunds, and audit scrutiny. The piece also points readers to recurring themes in CMS guidance and reporting so practices can focus on internal education and documentation review.
Why This Topic Matters
CERT findings can signal where practices are most vulnerable to payment errors, denials, and recoupment actions. Understanding the general categories of risk helps organizations target compliance review and training.
Article Sections
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Documentation Sorely Lacking
Introduces the CMS CERT report and summarizes the overall error-rate trends by year and by specialty. It sets up the major categories of billing and documentation problems discussed in the article.
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Avoid These Common Mistakes
Reviews several frequently cited service categories with elevated claim-error rates and discusses the broad documentation and coding concerns associated with them. The section focuses on common Part B compliance issues and practical audit awareness.
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E/M Visits Among ‘Problem Codes’
Highlights selected evaluation and management services and diagnosis groupings that were identified as problematic in the CMS review. It closes with a general reminder about documentation review and staff education.
What You Will Learn
- How CMS CERT findings are used to identify common billing and documentation risk areas
- Which broad service categories were highlighted as recurring problem areas
- Why documentation quality is central to avoiding claim errors and refunds
- How practices can use audit findings to guide internal education and review efforts
Who Should Read This
- Medical coders
- Billing staff
- Compliance officers
- Practice managers
- Physicians
- Auditors
Codes Discussed
Code Ranges Discussed
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