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What You Should Know About the Revised CERT Denials

February 06, 2019
Documentation, Billing, & Coding By Patty Klinefelter, Director

Almost all home health agencies are aware of the new Medicare Conditions of Participation (CoPs) changes that became effective January 13, 2018.  However, one requirement under the 42 CFR 484.60 CoP standard: Care planning, coordination of services, and quality of care, has created Comprehensive Error Rate Testing (CERT) denials.

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The revised plan of care standard (POC) includes a new item, information related to advance directives. In addition to being a CoP standard it also became a Condition of Payment standard, 42 CFR 409.43. Below is the standard.

 (a) Standard: Plan of Care 

(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration.

(2) The individualized plan of care must include the following:

(i) All pertinent diagnoses;

(ii) The patient's mental, psychosocial, and cognitive status;

(iii) The types of services, supplies, and equipment required;

(iv) The frequency and duration of visits to be made;

(v) Prognosis;

(vi) Rehabilitation potential;

(vii) Functional limitations;

(viii) Activities permitted;

(ix) Nutritional requirements;

(x) All medications and treatments;

(xi) Safety measures to protect against injury;

(xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors.

(xiii) Patient and caregiver education and training to facilitate timely discharge;

(xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient;

(xv) Information related to any advanced directives; and

(xvi) Any additional items the HHA or physician may choose to include.

 

CERT was established by Centers for Medicare & Medicaid Services (CMS) to protect the Medicare trust funds. Claims are randomly selected for review to identify payment errors. An error rate is calculated and used to evaluate Medicare contractor’s performance. Recent CERT audits have identified non-compliance with the standard noting an absence of advance directive information on the POC. Therefore, claims without this element listed on the POC are being denied. However, MAC’s audits have been paying these same claims. CMS, at this point, has not agreed to any remedial measures, despite the widespread non-compliance with the standard.

Actions an agency can take include:

  1. Review current process for developing POC and assess if advance directive information is incorporated into the POC.
  2. Communicate with software vendors to determine how to incorporate into the POC.
  3. Review medical records to identify presence of advance directive information.
  4. The National Association of Home Care (NAHC)has suggested obtaining an amended POC, with the required element, signed by certifying physician. Then, submit a corrected claim to the Medicare Administrative Contractor (MAC).

On January 15, CGS, a MAC for CMS, issued a urgent memo that was directed towards advanced directors. It stated:

The Home Health Conditions of Participation 42 CFR 484.60 state the Plan of Care (POC) must include "Information related to any advanced directives." If a Medicare beneficiary has advanced directives, a home health agency is advised to indicate this on the POC, which signifies that the specific directives from the beneficiary have been obtained and documented in your records.

What providers need to know:

It is not necessary for home health providers to re-bill or adjust previous claims submitted without the advanced directives on the POC.

CGS has not received direction from CMS to begin reviewing for this information on the POC. However, CGS is seeking clarification concerning this matter with CMS. Providers are encouraged to appeal these types of denials from the CERT program/contractor. The POC is required prior to submitting the claim for payment.  Therefore, submitting an addendum to the POC to add missing requirements after a claim was submitted would not be acceptable.

LW Consulting, Inc. is recommending agencies contact their MAC for direction. 

 

For more information regarding preventing denials, contact Patty Klinefelter, Director at  540-686-1311 or email  PKlinefelter@lw-consult.com.

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