Q&A: CERT’s role in coding auditing

Q: I've seen references to CERT reports regarding potential areas of Medicare coding risk. What exactly is CERT? 

A: The Improper Payments Information Act of 2002, amended by the Improper Payments Elimination and Recovery Improvement Act of 2012, requires CMS to calculate the national Medicare Fee-for-Service (FFS) improper payment rate. In response to these acts, CMS created the Comprehensive Error Rate Testing (CERT) program. This post-payment auditing function focuses on billing errors that result from the following:

• Insufficient documentation
• Incorrect coding
• Medical necessity
• No documentation
• Other issues, such as duplicate claims or non-covered services

The CERT contractor performs this function by randomly selecting a statistically valid sample of processed Medicare FFS claims and requesting the associated medical documentation from the provider. Once the records are received, a CERT professional audits the chart to determine whether the claim was paid appropriately. Using the audit information from the CERT, CMS then calculates a national FFS improper payment rate and uses it to measure the performance of the MAC and to gain insight into the causes of errors.

CMS publishes the results of these reviews annually. This information can be very helpful for a leadership team, as they can use the findings to pinpoint areas of risk related to documentation and coding. See CMS' Quarterly Provider Compliance Newsletter for more information on CERT reports. 

Editor’s note: This article originally appeared in the Revenue Cycle Advisor. This question was adapted from the HCPro book The Coder's Guide to Physician Queries by Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP, with contributions from Rose T. Dunn, MBA, RHIA, CPA, CHPS, FACHE.