CERT Error: Insufficient Documentation

Published 01/24/2022

When a provider receives a Comprehensive Error Rate Testing (CERT) error for insufficient documentation, it means that elements of the medical record that are imperative for Medicare payment are missing from the medical record sent in to the CERT contractor for review. Here are some tips to prevent this error:

  1. Remember, it is the billing provider’s responsibility to obtain the necessary information required for the record review, regardless of the location of the documentation
  2. Make sure that both sides of double-sided documents are submitted
  3. Ensure the documentation has legible signatures and dates. Signature logs should be included with record submission.
  4. Ensure the correct CPT or HCPCS code is used, if applicable
  5. Ensure all physician orders are included and authenticated
  6. Include test results and lab results, if applicable
  7. Make sure the copy sent to the CERT contractor is legible
  8. Number the pages before making a copy, so it will be easy to see if one of the pages is missing
  9. Use a checklist to ensure all of the essential pieces are included in the record