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Understanding CERT helps address clinical documentation deficiencies
Persuading physicians to document thoroughly and effectively is often a lesson in futility. Physicians have a natural instinct to believe they are either doing a proficient job of documenting or assert that they are too busy to document more than what is currently in the record. The physician typically does not recognize that this viewpoint can significantly impact his or her finances.
There appears to be a misconception in physicians’ minds that clinical documentation is for the benefit of the hospital in MS-DRG assignment. However, nothing can be farther from the truth. Physicians are subject to increasing numbers of pre- and post-payment audits in an effort to circumvent the “pay and chase” payment process that currently exists for paying physician service claims.
A Medicare initiative that immediately comes to mind is the Comprehensive Error and Review Testing (CERT) Program. Under the CERT program, CMS selects a random sample of claims from each Medicare contractor and requests medical records from the providers who submitted those claims. These records are then reviewed to determine if the claim was submitted and paid appropriately.
CMS utilizes two contractors for the request and review of medical records: the CERT Documentation Contractor (CDC) and the CERT Review Contractor (CRC). The CDC is responsible for requesting and obtaining the medical records. The CRC reviews the supporting documentation for compliance with Medicare coverage, medical necessity, coding regulations, and billing rules.
