CERT Error: Medical Necessity Not Met for Home Health Providers

Published 01/07/2014

When a home health provider receives a Comprehensive Error Rate Testing (CERT) error for Medical Necessity Not Met, it means the documentation submitted for review by the provider does not meet the coverage guidelines for the Home Health Medicare benefit. To prevent these error, make sure the following information is submitted in the record for review:

Plan of Care and Certification

  • Physician signature legible and dated
  • Signed and dated prior to billing the end of episode claim
  • Orders in proper format
    • Orders signed and dated
    • Verbal orders signed before billing the claim
    • Medication orders include name of drug, dosage, route and frequency
    • New and/or changed prescription medications
      • 'New' medications are those that the patient has not taken recently, i.e. within the last 30 days
      • 'Changed' medications are those that have a change in dosage, frequency or route of administration within the last 60 days

OASIS

  • Documentation to support the HIPPS code billed
  • OASIS in state repository

Face to Face Encounter

  • Completed 90 days before – 30 days after start of care
  • Includes clinical findings to support the need for skilled services
  • Documentation supports homebound status

Documentation to support beneficiary is appropriate for Medicare Home Health Services (not an all-inclusive list)

  • New onset or acute exacerbation of diagnosis
  • Acute change in condition
  • Changes in treatment plan as a result of changes in condition (i.e. physician’s contact, medication changes)
  • Changes in caregiver status
  • Complicating factors (i.e. simple wound care on lower extremity for a patient with diabetes)
  • Homebound status is supported
  • Need for a skilled service is supported

Therapy Documentation

  • Orders include frequency and duration
  • 'Eval and treat' orders are followed up with specific interventions
  • Measurable goals for each discipline
  • Skilled care evident on each note
  • Every note signed and dated
  • Notes reflect progress towards goals
  • Assessments completed
    • Initial assessment contains assessment of function which objectively measures activities of daily living
    • Reassessments performed timely to reassess the beneficiary and compare resultant measurement to prior measurements
    • Assessments performed by therapist, not assistants
  • Inherent complexity of services that causes them to be safely and effectively provided only by skilled professionals
  • Physician orders have documentation that the intervention ordered took place

Nursing Documentation

  • Daily skilled nurse visit orders contain frequencies w/ indication of end point
  • If insulin administration is reason for service, documentation of why beneficiary or caregiver cannot administer
  • Skilled care evident on each note
  • Every note signed and dated
  • Visits consistent with physician orders
  • If teaching and training, clear documentation of tasks to be taught and progress toward beneficiary/caregiver accomplishing that task
  • For observation and assessment, documentation of beneficiary status after 21 days
  • Inherent complexity of services that causes them to be safely and effectively provided only by skilled professionals
  • Physician orders have documentation that the intervention ordered took place