CERT Audits

CERT Tip Sheet: Appeals

Documentation Submission Responsibilities (Updated: 1/3/2012)

When medical records are requested, the billing supplier is responsible to obtain sufficient documentation to support the medical necessity of the service(s) billed. If the documentation is insufficient to support medical necessity, the claim may be denied.* National Government Services expects that the patient’s medical records will reflect the need for the medical care provided.

The supporting documentation includes any third party documentation, such as the treating physician’s documentation, that may be available only through the physician’s office.

When submitting records for review to National Government Services or the Comprehensive Error Rate Testing (CERT) contractor, please ensure:

Documentation is legible including the physician’s signature and no highlighting is used on medical records
Records are for all services and dates of service on the claim
The medical records submitted provide proof that the service(s) was ordered, rendered by the medical doctor (MD) or appropriate non-physician provider, and provide justification to support the medical necessity
When submitting records for review to the CERT contractor, please complete the following steps:
Photocopy (front and back) the requested record as identified in the CERT contractor request
Submit the CERT bar code sheet with a copy of the medical records or a cover sheet with the CID#

Fax or mail the medical records to the CERT contractor:
Preferred method of receiving records is via fax at 240-568-6222
If unable to fax records (especially large records) may be submitted on a CD or hardcopy.
If hardcopy, mail to:
CERT Documentation Office
Attn: CID #
9090 Junction Drive, Suite 9
Annapolis Junction, MD 20701

Suggested documentation to be obtained (not all inclusive and depends on the services billed) is as follows:

Physician progress notes documenting visit billed or medical necessity of services ordered
Physician orders (for inpatient hospital, observation, laboratory, diagnostic and therapeutic services)
Treatment plans—initial and current (with physician signature)
Nurses’ notes
Medication administration records
Graphic reports
Operative reports
Pathology reports
Consultation notes
Referring physician report
Laboratory reports
Diagnostic test results (regardless of where they are performed)
History and physical notes
Hospice records
Home health progress notes
Certificate of Medical Necessity
Skilled nursing facility records (including minimum data set [MDS] look back periods)
Ambulance records
Emergency room records
Therapy progress notes and reports
Treatment logs with documentation of total treatment time for timed modalities
Initial evaluations and current reevaluations for ongoing therapeutic services with MD signature and diagnoses and conditions showing medical necessity
Inpatient hospital admission evaluation and information to support medical necessity of inpatient stay.

In the case of inpatient admission for surgery, include documentation from prior to admission/surgery such as progress notes showing:

conservative treatment attempted (medications, therapy)
patient symptoms/conditions (necessitating surgery)
radiologic evidence (showing need for surgery)
Inpatient Rehabilitation Assessment Instrument (IRF-PAI) for inpatient rehabilitation service(s)
Chiropractic treatment plan notes/logs including the previous six months treatment documentation if for the same condition as sampled claim

Note: Where a physician signature is required, signature key or attestation statement is needed if signature is not legible. This should include physician typed or printed name and signature. If orders are on an electronic ordering system, include protocol describing the process, i.e., physician enters the electronic system with unique ID and password.

For more information please contact the Provider Contact Center (PCC) located under Resources > Contact Us.

* Section 1833(e) of the Social Security Act precludes payment to any provider of services unless “there has been furnished such information as may be necessary in order to determine the amounts due such provider.”