Podiatry Coding & Billing Alert

Hint: Know your appeal rights when it comes to CERT.

Whether you have been coding for two months, two years, or 20 years, you have probably heard of the acronym CERT - the Comprehensive Error Rate Testing program. Understanding the CERT program is vital because it identifies common medical coding errors and assesses error rates.

Read on to learn more about how CERT works and how to avoid costly coding mistakes in your podiatry practice.

Avoid These Common CERT Podiatry Coding Mistakes

The Medicare administrative contractor (MAC) Noridian offers a helpful tool on its website where it breaks down common CERT errors by specialty. Here are some common CERT errors caused by insufficient documentation and incorrect coding you want to strive to avoid in your podiatry practice specifically regarding evaluation and management (E/M) codes, CPT^® code 29425, and HCPCS code Q4038:

• The documentation supported a CPT^® or HCPCS code change (down or up code).
• The CPT^® code was missing supportive documentation such as pre-procedural, conservative measures, pain assessment, evaluation, and clinical documentation.

Don't miss: CERT identified the following as codes people commonly make mistakes with when reporting: 

• 29425 (Application of short leg cast (below knee to toes); walking or ambulatory type)
• Q4038 (Cast supplies, short leg cast, adult (11 years +), fiberglass).

Tip for reporting 29425: When reporting 29425, remember that the application of a cast may be included in the primary code for an associated surgical procedure. Replacement of the cast at a later date may be included in the global period of the surgical procedure or it may be separately reportable. You should check with your payer for confirmation.

Tip for reporting Q4038: Q codes represent reimbursement of temporary codes for supplies, drugs and other biological devices that do not have any permanent code. For other casting supplies, you should look to codes Q4001 (Casting supplies, body cast adult, with or without head, plaster) through Q4050 (Cast supplies, for unlisted types and materials of casts). For each casting supply code, you should bill only one unit per cast.

Discover how CERT Works for Clarity

During each reporting period, CERT chooses a stratified random sample of claims submitted to A/B Medicare administrative contractors (MACs) and Durable Medical Equipment MACs (DMACs) and requests that the provider and or the suppliers who submitted those claims provides the supporting medical documentation.

Then, an independent medical review contractor reviews these claims to see if they were correctly paid per Medicare coverage, coding, and billing requirements. The current medical review contractor is AdvanceMed, and the current statistical contractor is The Lewin Group, Inc.

Upon review, if AdvanceMed discovers that criteria was not met in those claims or if the provider didn't submit the proper medical documentation to sufficiently support the billed claim, the claim is identified as either a total or partial improper payment. The improper payment may be recouped for overpayments or reimbursed for underpayments, CMS says.

CMS calculates the results of this review, and this becomes the national, annual Medicare Fee-for-Service (FFS) improper payment rate. The Department of Health and Human Services (HHS) publishes these results in its agency financial report (AFR).

Why should this matter to you? This improper payment rate calculation is important because it measures the MACs performance and gives CMS insight into what caused the claim submission errors, according to a CMS fact sheet about Medicare claim review programs.

Don't miss: "The improper payment rate is not a 'fraud rate,' but is a measurement of payments that did not meet Medicare requirements," CMS says on its website. "The CERT program cannot label a claim fraudulent."

Always Respond to CERT Requests

You can respond to a CERT request in several ways, according to Michael Hanna, MPA, CDME, provider outreach and education consultant at CGS-DME MAC Jurisdiction C in Nashville, Tennessee, in a recent webinar:

• Fax - this is the preferred method, Hanna said. "Always include the barcode sheet as part of your fax package. This simply marries the documentation you're submitting with that particular date of service the CERT contractor has chosen for a review."
• The electronic submission of medical documentation system (esMD). With this method, you use the gateway you contracted with and follow standard procedure.
• Mail - "If it's a sizeable amount of documentation, or you've already saved it to a CD, you can mail it in," Hanna added.

Don't miss: You can make extension requests by telephone only.

Caution: Normally, the CERT contractor only grants extensions in extreme circumstances such as natural disasters like hurricanes, tornadoes, and ongoing fires, according to Hanna.

"But, if you are simply waiting on medical records from the physician, it is possible the CERT contractor may not grant that extension," Hanna said. "If that is the case, you should always send the CERT contractor what you have available, and then if they disagree or find something missing or not valid, you do have appeal rights."

Any claim errors the CERT contractor finds will result in a revised Medicare admittance advice where they will deny that claim and an overpayment demand where they ask you to recoup the money, Hanna cautioned.

Be Aware of Your Appeal Rights

As mentioned previously, you have appeal rights when it comes to CERT. The MAC Novitas does a good job of identifying how this appeals process works.

The first level of appeal is called a "redetermination." You must submit your redetermination request in writing and file it within 120 days from the date on your RA (Remittance Advice) or MSN (Medicare Summary Notice).

You must include all of the following information with your appeal request, according to Novitas:

• The patient's name
• The patient's Medicare Beneficiary ID
• The CERT identification (CID) number
• The date CERT made its initial determination
• The service or items you're requesting the redetermination for
• The date of service
• Both the printed name and signature of the person making the request.
• The printed name and signature of the person making the request
• An explanation of the requestor's relationship to the providing physician.

When you submit a redetermination request, you must also include any information that supports the coverage of the appealed service. And if the denial happened because you did not respond to an Additional Documentation Request (ADR) in time, then you must also include the information requested in the ADR, along with your appeal request.

Resource: To learn more about the CERT program, visit http://www.cms.hhs.gov/CERT/.