Health Information Management

News: CERT report points to documentation insufficiencies

CDI Strategies, August 5, 2010

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Three types of mistakes—insufficient documentation, miscoded claims, and medically unnecessary services and supplies—accounted for nearly 98% of errors common across six different provider types, according to the July 14 report Analysis of Errors Identified in the Fiscal Year 2009 Comprehensive Error Rate Testing (CERT) Program, released by the Office of the Inspector General (OIG).

The provider types included:
  • inpatient hospitals
  • durable medical equipment suppliers
  • hospital outpatient departments
  • physicians
  • skilled nursing facilities
  • home health agencies
These providers accounted for $4.4 million, or 94%, of the total $4.7 million in improper payments. Improper payments totaling more than $1.9 million for 400 inpatient hospital claims accounted for 40% of that $4.7 million.
 
For inpatient facilities, medically unnecessary services or services which could have been performed in a “less intensive setting” accounted for mistakes in 123 claims. The improper payments amounted to $718,414. According to the report, such services may have been provided so that the beneficiaries could qualify for placement in SNFs.
 
The report indicates that roughly $600,000 in improper payments were made on 91 inpatient claims because the medical records did not include sufficient documentation. These included the following areas of deficiency:
  • physician progress notes, diagnostic test results, and/or discharge summaries (63 claims with improper payments totaling $453,227)
  • results of examinations or treatments and/or emergency room records (23 claims with improper payments totaling $131,799)
  • physician orders and other documentation (five claims with improper payments totaling $27,085)
The CERT contractor determined that miscoded diagnoses or procedures accounted for errors on 182 inpatient claims totaling $558,011. For example, “a hospital was paid $17,283 for an excision and debridement procedure. The CERT contractor concluded from the documentation in the medical record that the hospital performed a less complex surgical procedure than the one coded by the hospital. The CERT contractor’s correction of the procedure code reduced the payment by $11,237.”

Editor's Note: Read more in Glenn Krauss' blog post regarding the report and the increased need to focus on quality care in healthcare documentation practices.



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