Case Management

Mentor moment: Understanding CERT helps address clinical documentation deficiencies

Case Management Weekly, February 10, 2010

The following article is adapted from HCPro’s resource for hospital case managers——a free blog dedicated to connecting hospital case managers to industry pacesetters, peers, and best practices.

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. Physicians typically don’t recognize that this viewpoint can significantly impact their finances.

There appears to be a misconception among physicians that clinical documentation is for the benefit of hospitals 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 in which CMS selects a random sample of claims from each Medicare contractor and requests medical records from the providers that submitted those claims. These records then are reviewed to determine whether the claim was submitted and paid appropriately.

CMS uses 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.

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