The following information was pulled from PalmettoGBA Article:  NORTH CAROLINA HOME HEALTH CERT INFORMATION 2018:  

The Comprehensive Error Rate Testing (CERT) program looks for improper payments on Medicare claims. Based on the 2018 annual report, here is the home health CERT information for North Carolina.

• Total claims reviewed: 27

• Total dollars reviewed: $66,078.09

• Claims paid: 25

• Dollars paid: $63,224.31

• Claims denied: 2

• Dollars Denied: $ 2,853.78

• Claims with error code Insufficient Documentation (21): 2

• Claims with error code Incorrectly Coded (31): 1

• Claims with error code Other Errors (90): 4

CERT Reviewer Error: 21 — Insufficient Documentation 
Error Subcategory: 00166 — Home Health — Face-to-Face Evaluation is Inadequate
There is insufficient documentation to support the billed home health episode. The face-to-face documentation for encounter lacks a narrative of clinical findings which supports homebound status. Documented as clinical findings is “HTN, OA, Colon CA ASHD — SN needed for observation, assessment, monitor med compliance” and homebound status is documented as “Due to joint pain caused by OA patient mobility is limited as tolerated.” There is no further explanation of how this beneficiary is rendered homebound. 

How to avoid errors for Face-to-Face Evaluation is Inadequate: 
The certifying physician must document that he/she or an allowed nonphysician practitioner (NPP) had a face-to-face encounter with the patient, including the date of the encounter. The documentation of the encounter must describe how the patient’s clinical condition as observed during that encounter supports the patient’s homebound status and need for skilled services. The certifying physician must document the encounter either on the certification, which the physician signs and dates, or on a signed addendum to the certification. 

CERT Reviewer Error: 21 — Insufficient Documentation 
Error Subcategory: T1 — Physical/Occupational/Speech Therapy — Plan of Care Is Missing or Inadequate
There were 4 PT visits billed, however there were no physician orders for the visits.

How to avoid errors for Plan of Care Is Missing or Inadequate: 
Ensure that the appropriate plan of care (POC) is included and that it is legibly signed and dated by the physician prior to billing. A plan of care refers to the medical treatment plan established by the treating physician with the assistance of the home health skilled professional. The POC contains all pertinent diagnoses, the patient’s mental status, the types of services, supplies, and equipment required, the frequency of visits to be made, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, all medications and treatments, safety measures to protect against injury, instructions for timely discharge or referral and any additional items the HHA or physician chooses to include. The physician must certify that the home health services were required because the individual was confined to his/her home and needs intermittent skilled nursing care, physical therapy and/or speech-language pathology, or continues to need occupational therapy; a plan for furnishing such services to the individual has been established and is periodically reviewed by a physician; and the services were furnished while the individual was under the care of a physician.

CERT Reviewer Error: 31 — Service Incorrectly Coded 
The billed HIPPS code is incorrectly coded. Documentation supports a change in HIPPS code for home health subsequent episode for billed DOS. Billed was 1BGKS which was adjusted per therapy threshold edit to 1BGMS. Provider had projected no rehab visits and had billed for seven (7) therapy visits. However, there are no orders to cover four (4) of these therapy visits. 

How to avoid errors for Service Incorrectly Coded: 
To avoid down codes for this reason, the documentation should paint a consistent picture of the patient’s condition.

CERT Reviewer Error: 90 — Other Errors 
Error Subcategory: 00179 — Incorrect HCPCS Billed on Line Not Affecting the HHRG
Lines were billed with incorrect HCPCS codes.

How to avoid errors for Other Errors: 
Ensure that all charges for accuracy/timeliness prior to submitting the final bill to Medicare. Check to ensure that all documentation submitted in response to the CERT Request corresponds to the service(s) rendered and the dates of service(s) billed.