Cert Reviews

Have the rules changed for CERT (Comprehensive Error Rate Testing) reviews?

Question: My office manager is telling me that the rules have changed about carrier reviews, as things have gotten harder in terms of what a payer will look at or consider. Does my EHR office note have to contain everything?

Answer: What she may be talking about are the CERT reviews - Comprehensive Error Rate Testing. These rules became more stringent back in 2009. In several areas the review rules have tightened:

•CERT used to apply clinical review judgment in considering medical record entries with missing or illegible signatures. Now, CERT disallows entries if a signature is missing or illegible.

• In the past CERT would consider an unsigned requisition or physicians' signatures on test results. Now, CERT requires evidence of the treating physician's intent to order tests, e.g., signed orders and progress notes.

•Previously, CERT would review available documentation, including physician orders, supplier documentation, and patient billing history, and apply clinical review judgment. Now, CERT requires medical records from the treating physician and does not review other available documentation or apply clinical review judgment.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years. He can be reached at billdacey@msn.com or editor@physicianspractice.com.

This article originally appeared in the February 2011 issue of Physicians Practice.