Guest Post: Use CERT data to address clinical documentation deficiencies

by Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS

Editor’s note: Glenn Krauss originally wrote this post for our sister publication the Case Management Mentor. I have included it here, with his permission, due to our recent CERT postings and his focus on documentation efforts.

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.

The CERT program findings

Every six months, the CERT Program releases two figures, which are calculated based on a review of approximately 130,000 Medicare patient encounters. These two calculations are the paid claims error rate and the provider compliance error rate. While the types of errors vary over time, the following errors are consistently identified as part of the physician medical record sample:

• Documentation in the record for the patient encounter does not support the level of physician evaluation and management code billed.
• The medical record documentation does not indicate and validate that the physician actually evaluated the patient.
• The record lacked documentation of a patient complaint (i.e., the presenting problem in the patient’s words)
• The medical necessity for the care provided was not readily apparent through review of physician documentation. A common error consists of the physician not signing and dating the progress note.

Capitalizing on the CERT program errors

Clinical documentation improvement programs certainly help spread the word that accurate and complete clinical documentation affects the physician’s practice of medicine.

Refer to the noted payment errors. How often do we see instances in daily progress notes where there are no diagnoses, no documented plan of care, insufficient documentation demonstrating the physician actually saw and evaluated the patient?

Use these documentation deficiencies and oversights to educate and engage the physician on “what is in it” for him or her. By educating physicians on the financial impact of incomplete medical record documentation, we are helping the physicians, the CDI program, and so on through multiple hospital departments.

Clinical documentation directly contributes to patient success in:

• Moving the patient along the continuum
• Addressing medical necessity for admission
• Determining the most appropriate level of service (outpatient, observation, or inpatient)
• Justifying and substantiating continued stay
• Supporting and serving as a building block for discharge planning

Read more about the CERT Program at the Medicare CERT Program Web site.

Editor's note: Krauss, at the time of this article's release, was Executive Director of the Foundation for Physician Documentation Integrity.