Comprehensive Error Rate Testing (CERT) Documentation Tips

Medicare has specific guidelines when it comes to documentation, and the CERT Contractor must follow these rules whenever they review documentation. It is important for providers to have clear, accurate and complete medical documentation.

Unfortunately, on many occasions, CERT finds the documentation received does not support the procedures being billed. Sometimes, it is something as simple as legibility of the writing or incomplete notes. Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a hand written or an electronic signature.

Stamp signatures are not acceptable. On some occasions, the documentation issue may involve “cookie cutter” templates where the patient complaints, physician notes/documented procedures, and the medical findings are identical for the majority of beneficiaries. It is the responsibility of the provider to ensure services billed to the Medicare program are accurate and represent the individual care given to the patient. Medical documentation needs to be unique, specific, and should accurately reflect the services being billed. The services billed should:

• Clearly address the presenting problem(s) on the date in question
• Provide an overview of all services rendered on the date in question
• Contain a legible signature of the rendering provider

Example: If you write an order for the patient to obtain an x-ray, make sure that you retain a copy of the order in the patients chart, or there is a clear note addressing the order in the patient’s medical record. The record would need to clearly document the intent for the x-ray.

Remember to keep in mind:
• If your notes are handwritten, make sure they are legible. If the reviewer can’t decipher the documentation, the service may not be allowed. You can have the records transcribed and submitted along with the handwritten notes.
• If your signature is not legible, providers can submit an attestation statement to clarify they rendered the service in question.If you perform a test, the order should be noted somewhere in the medical record.
• Include patient history documents to help substantiate services.
• When billing for timed codes, note the actual time in the chart and make certain your documentation clearly reflects the time you spent.

Fax Medical Records!
Highmark Medicare Services’ Medical Review Department recently implemented a process by which providers can fax in medical records in response to an Additional Documentation Request (ADR). This fax option is available 24 hours a day, 7 days a week.

Medical records that do not exceed 200 pages can be sent to our office via fax. If you choose this option, please be sure to include as a cover sheet the first page of the ADR/cover sheet provided followed by the medical records.

Please fax each claim individually with the corresponding cover sheet. Providers opting to utilize the fax method must fax the first page of the ADR or cover sheet followed by all supporting medical records to the following number: 1-877-439-5479
You can also continue to submit medical records by mail. All hard copy medical records should be sent to the following address:

Highmark Medicare Services
Attention: Medical Review Part A
Post Office Box 890385
Camp Hill, PA 17089-0385


Highmark Medicare Services
Attention: Medical Review Part B
Post Office Box 890065
Camp Hill, PA 17089-00065

Another option is to send medical records via Express mail. Express mail should be sent to the following address:

Highmark Medicare Services
Medical Review Part (A or B)
1800 Center Street
Camp Hill, PA 17089

Attention: (insert Clinical Reviewer’s name if provided)
All medical record requests will continue to follow the same guidelines related to timeliness, legibility and completeness. You are encouraged to review the medical records prior to submission to ensure that all the requested documentation is provided and that the documentation is legible. Review the medical records for services requiring physician orders.

In some cases, authentication by the ordering physician could be submitted with the initial medical record request. As always, we encourage you to submit the medical records in a timely manner in order to prevent unnecessary denials.