The Centers for Medicare and Medicaid Services (CMS) has several programs they sponsor and/or support that target “improper payments”. One of those programs is Comprehensive Error Rate Testing or CERT. The purpose of CERT is to measure the Medicare Fee-For-Service (FFS) improper payments, which include Medicare Part A, Part B and Durable Medical Equipment and Suppliers.  Basically, the CERT program measures payment compliance with Medicare FFS program federal rules, regulations, and requirements, something we all care about.

The definition of “Improper payment” is a payment that should not have been made or payments made in an incorrect amount. It should be noted that both overpayment and underpayments are considered to be improper payments per the CERT program. This would include:

  • Payments to an ineligible recipient
  • Payments for an ineligible service
  • Duplicate payments
  • Payment for services not received
  • Payment for the incorrect amount

The process that CERT uses in order to determine the error rate involves the following steps:

  1. Claims Selection
  2. Medical Record/Encounter review
  3. Medical Review
  4. Calculation of Error Rate
  5. Reporting of Findings

Obtaining and reviewing the CERT findings is key to coding compliance efforts for all FFS settings because of the CERT error categories have a link to medical coding. Improving coding quality and accuracy is vital to revenue cycle and compliance, thus knowing where CMS finds errors is extremely important. The CERT error categories are:

  • Insufficient Documentation
  • Medical Necessity
  • Incorrect Coding
  • No Documentation
  • Other

Obtain the CMS CERT reports at: CERT Reports | CMS and for the 2020 report go to: 2020_Medicare Fee-for-Service_Supplemental_Improper_Payment_Data (cms.gov)

The most recent published error rate was for FY2020 and showed an overall error rate for FFS of 6.27%, which equates to $25.74 billion in overpayments.   During the COVID-10 Public Health Emergency there was a pause in the CERT activities, however, they were resumed on August 11th, 2020.

Visit the CMS Cert site at: Comprehensive Error Rate Testing (CERT) | CMS

Click here to contact Reimbursement Management Consultants (RMC) for assistance with medical coding support, auditing, compliance, and CDI. RMC is a Woman-owned, US-based, and operated company which specializes in a variety of medical coding compliance services.

Written by Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA Approved ICD-10-CM/PCS Trainer