What is CERT and Why is it Important?

As I speak around the country, I am often amazed at the amount of anxiety and insecurity that ODs have when it comes to being audited. In my discussions with providers, this fear of audit is almost always related to selecting the wrong 99XXX or 92XXX code. There is no question that being audited is a pain. However, we should not use this fear of being audited as a reason to under-code our levels of examination.

Comprehensive Error Rate Testing (CERT) is a method that CMS uses to "evaluate improper payments by evaluating a statistically valid stratified random sample of claims to determine if they were paid properly under Medicare coverage, coding, and billing rules." If we analyze CMS data on (CERT), we will see that optometrists actually have an improper payment rate that is about half of the general Medicare Part B rate for ALL physicians. To say this another way, as a profession optometrists are about 2 times more likely to be appropriately paid than the entire cohort of physicians.

Lets look at the numbers:

This would make it seem that optometrists would actually be less likely to be flagged in an audit. So why are we all so concerned? Possibly it is because we don't know what will cause an audit to be triggered. Lets look at the common areas for ODs to fail under an audit:

The first thing I notice when I look at this list is that it has nearly nothing to do with 99XXX and 92XXX codes! The second is that nearly ALL of these should be easily avoided with solid protocols and documentation techniques.

Bottom Line

Don't fear an audit, protect against one. Not by under-

coding but by making sure you understand when to use the correct level of code, document appropriately and don't miss something simple like signing your charts!