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Summary of Common Errors Identified by the Comprehensive Error Rate Testing Program

The Comprehensive Error Rate Testing (CERT) Program was implemented by the Centers for Medicare & Medicaid Services (CMS) to monitor the accuracy of claims processing by Medicare contractors, like Cahaba. Contractors are then notified by CERT of the errors and findings.

Cahaba uses this information to conduct data analysis and determine the magnitude of the error and/or finding. This data analysis aids us in the implementation of corrective actions, such as probe reviews and provider education. Cahaba reports these corrective action activities to the CMS in an Error Rate Reduction Plan (ERRP).

We encourage all providers to review this listing to educate you on common errors.The intent in providing this information is to prompt you to conduct an internal analysis of Medicare billing and reduce future denials by Medicare.

 

Home Health Identified Errors

 

Provider Type TOB Error Indentified by CERT
Home Health 329 Provider billed 5BHKT in anticipation of 20 therapy visits.  Provider billed 6 visits, but HIPPS was further reduced to 3BHKT as documentation supported only 5 visits provided.
Home Health 329 Plan of care was not submitted to CERT. Claim denied in full. 
Home Health 329 Primary diagnosis on claim indicates congestive heart failure.  However, documentation supports CHF stable, and primary need is infrared therapy, which is not medically necessary under Medicare regulations.
Home Health 339 Provider billed two therapy visits that were not provided based on documentation submitted.  HIPPS code reduced to 1BGK1.
Home Health 329 Seven therapy visits billed; however, no orders to support the resumption of care by physical therapy for two visits. Therefore, HIPPS code reduced to 1AFK1.
Home Health 329 Five nursing visits reported on LUPA claim.  However, patient was discharged from home health before last reported visit.  LUPA claim reduced from 5 visits to 4 visits. 
Home Health 329 Provider billed 10 therapy visits on claim.  However, no documentation to support one SLP visit.  HIPPS code reduced to 1AGM1. 
Home Health 339 Documentation supports patient independent with ADLs and driving self to dr’s appointments.  Home health is not reasonable and necessary.  All services denied.
Home Health 329 Claim billed before agency received signed home health plan of care.  All services denied.
Home Health 329 Provider billed 1BFN1 indicating 10 therapy visits.  System upcoded to 1BFP1 as provider billed 11 therapy visits on the claim.  Documentation only supported 10 therapy visits provided.  HIPPS reduced to 1BFN1. 
Home Health 339 Error in response to M0250. Documentation the beneficiary performs intermittent self-catheterizations due to urinary retention and also has urinary incontinence. The clinician marked the answer as '1 Pt. is incontinent.' The correct answer is '2 Pt. requires a urinary catheter
Home Health 329 Documentation states that patient doing well, and leaves home daily with son to walk mall, shop, etc.   Services not reasonable and necessary as patient is not homebound.
Home Health 329 Downcode HIPPS to 5BHKT from 4BHKT.  This is an early episode with 23 therapy visits.            
Home Health 329 M0670 [bathing] question on the OASIS Recertification Assessment from the RHHI extract has the answer of '1.'  However, the submitted paper copy of this OASIS assessment has the answer marked as '3.' Per CSR call the provider responded stating there was a data entry error for M0670 and the correct answer was 3 not 1. HIPPS code changed to 3BGK1.
Home Health 329 Discrepancies exist between the answers in the clinical record for the M0670, 680 and M0700 questions compared to answers found in RHHI extract summary.  Documentation indicates the answer to M0670 was 3 not 2; M0680 was 1 not 2 and M0700 was 2 not 1. The answers were supported in the PT eval section of the clinical record. Of additional note is that M0800 injectable med question was answered as '1 able to take injectable medications at correct times." There was no documentation to support this answer. Per the POC and the med sheet beneficiary was on no injectable meds. The correct answer to M0800 is 'NA no injectable meds.'  Correct HIPPS code is 1BGN1.
Home Health 329 Provider billed 1BGM1 and twice daily PT visits on four days.  Documentation supports only 1 PT visit each day.  HIPPS code changed to 1BGK1. 
Home Health 339 No physician’s order to support medical necessity of OT visits provided.  
Home Health 329 The Plan of Care submitted for review is missing the date the physician signed the Plan of Care and/or the date the agency received the Plan of Care from the physician after it was signed. Services denied for insufficient documentation.
Home Health 339 Insufficient documentation to support HH visit.  Provider states visit billed in error.   
Home Health 339 Orders received to cover the OT evaluation, but not the subsequent 3 OT visit. 
Home Health 329 Discrepancies found in answers to M0476 [status of stasis ulcer] which had been marked as '1' in RHHI but was NA in clinical documentation and in M0490 [Dyspnea] marked as 4 in RHHI but 3 in clinical documentation. Changing values for M0476 and M0490 generated corrected HIPPS of 1BFK1.
Home Health 329 Discrepancy found in the answer to the M0250 question [Therapies the patient receives at home] on the OASIS Recert assessment. Per orders portacath is to be accessed and flushed by SN. Clinician marked answer as '4 none of the above.'
Home Health 329 The physician signed home health plan of care/certification was not submitted. 
Home Health 329 POC had orders to cover PT services provided for 1 visit. There were no orders for PT HV billed for three additional dates. HIPPS code reduced to 4CGK1.
Home Health 329 Per SN home visit note, patient is driving and having no trouble leaving home on a regular basis.   Services medically unnecessary as patient is not homebound. 
Home Health 329 Service incorrectly coded as late episode.  However, CWF and submitted documentation indicates this is early episode.  HIPPS changed accordingly.
Home Health 329 No response to CERT request.

 

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Hospice Identified Errors

Provider Type TOB Error Identified by CERT
Hospice 813 Missing election statement, certification and signed plan of care for services billed.
Hospice 824 Provider billed 13 days of routine home care.  However, documentation only supports 10 days of care provided.  Patient was discharged on day 10.  Three days of RHC were denied.
Hospice 814 Missing plan of care for hospice visits. 
Hospice 813 Medical records for services submitted, but are poor copies and illegible.  Provider stated they did not have the requested records.  Services denied for insufficient documentation.
Hospice 812 Attending physician’s documentation indicates questionable terminal status.  Services denied as not reasonable & necessary.   
Hospice 823 No documentation received per CERT request.   Claim denied in full.

 

 

Page last updated: July 2, 2010

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