NHIC (Jurisidiction A) CERT Error Findings for Nov 2012

Below are results from Jurisdiction A NHIC on Cert errors from November 2012, not quite 1 year ago.  When reviewing the results of the various types of equipment, be sure to note the lack of documentation to support the medical need of the item being order and lack of documentation to support that the indicated equipment is benefiting the beneficiary and the need for continued use.  There was a consistency in lack of a completed detailed order whether it was missing certain items received by the beneficiary or the treating physician’s signature and date.  By taking a few moments to review this report and sharing with your team will benefit your understanding of the coverage criteria.   If you have any questions, please contact US Rehab at 800-987-7342.

September 12, 2013

November 2012 CERT Errors

In an effort to help reduce the CERT Error Rate, NHIC, Corp. DME MAC A is providing monthly claim examples reviewed by the CERT contractor, resulting in the top CERT Errors. As you review this information, consider the missing documentation that caused the error.

DME MAC A expects these examples will assist suppliers in understanding the CERT review process, and to become familiar with the type of medical records requested.

For information on coverage and documentation requirements, you may access the applicable Local Coverage Determinations (LCDs) at the following web site: http://www.medicarenhic.com/dme/mrlcdcurrent.aspx 

The following examples are errors cited during the CERT review for November 2012:

  1. Glucose Monitors and Supplies – LCD L11530

    A4253-NU-KX – Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips

    # of units billed = 2

    Date of Service: 05/15/12 to 06/03/12

    • Received – Unauthenticated testing logs.
    • Missing – A valid signed and dated order for strips and glucose testing; clinical documentation supporting medical need for testing (4) times per day as ordered that exceeds utilization guidelines for insulin treated patient (testing logs reflecting testing 4 times daily); clinical documentation supporting ongoing current medical management of diabetes by ordering physician; medication/insulin information used to treat diabetes; confirmation of beneficiary compliance with a physician’s treatment plan of home monitoring; documentation to support the treating physician has seen the patient and has evaluated their diabetic control within 6 months prior to ordering quantities of diabetic supplies that exceed the utilization guidelines.

A4253-NU-KX – Blood Glucose test or reagent strips for home blood glucose monitor, per 50 strips

# of units billed = 8

Date of Service: 06/01/12 to 08/19/12

    • Received – Refill prescription dated 12/17/10 stating “4 to 5 times a day” testing frequency; prescription details.
    • Missing – Clinical records that support medical management of an insulin treated diabetic, including medication(s) used to treat diabetes; clinical documentation to support the need, and specific reason for ordering testing that exceeds the utilization guidelines of three times a day testing for an insulin treated diabetic; office visit notes supporting that the treating physician has seen the beneficiary and has evaluated their diabetic control within 6 months prior to ordering (12/17/10) quantities of diabetic supplies that exceed the utilization guidelines; documentation to support beneficiary is testing at the prescribed frequency of “4 to 5 times a day.”  

  1. Lower Limb Prostheses – LCD L11464

    L5321-LT – Above knee, molded socket, open end, SACH foot, endoskeletal

    L5624-LT – Addition to lower extremity, test socket, above knee

    # of units billed = 2

    L5631-LT – Addition to lower extremity, above knee or knee disarticulation, acrylic socket

    L5650-LT – Addition to lower extremity, total contact, above knee or knee disarticulation socket

    L5651-LT – Addition to lower extremity, above knee, flexible inner socket, external frame

    L5671-LT – Addition to lower extremity, below knee/ above knee suspension locking mechanism, excludes socket insert

    Date of Service: 05/30/12

    • Received – Physician signed and dated order for the replacement items billed on this claim; physician letter of medical necessity; unauthenticated Care Plan Oversight (CPO) evaluation dated 04/10/12 that documents recommendations for prosthesis and components (but no documentation to support that the components and prosthesis replaced was provided). The note by the prosthetist was not authenticated, but was later altered with a signature added.
    • Missing – Authenticated prosthetist documentation of the replacement of the prosthesis, prosthetic components replaced, and the reason for replacement as required in the governing LCD; documentation of the beneficiary’s past history, beneficiary’s current condition including the status of the residual limb and the nature of other medical problems; documentation to support beneficiary’s desire to ambulate; documentation to support physician oversight.

L5020-RT-KX – Partial foot, molded socket, tibial tubercle height, w/ toe filler

L5668-RT-KX – Addition to lower extremity, below knee, molded distal cushion

# of units billed = 2

Date of Service: 06/27/12

    • Received – Order for billed items; statement for therapeutic shoes; procedure note dated 06/06/12 for a right TMA; history and physical dated 06/25/12 and 07/03/12 (unsigned); supplier evaluation; delivery; supplier adjustment appointment documentation; progress note dated 06/06/12 that documents ordering a custom brace.
    • Missing – Documentation from the referring physician that includes an evaluation of the residual limb and gait, assessment of beneficiary’s rehabilitation potential, current functional capabilities, and expected functional potential with explanation for the difference; documentation supporting that the beneficiary will reach or maintain a defined functional state within a reasonable period of time with use of prostheses; documentation that supports the beneficiary is motivated to ambulate.

  1. Power Mobility Devices – LCD L21271

    K0800-RR-KX – Power operated vehicle, group 1 standard, patient weight capacity up to and including 300 lbs

    Date of Service: 06/06/12

    • Received – 7-element order dated 12/7/11; Detailed product description dated 12/28/11; Home assessment dated 01/06/12; a prescription dated 11/23/11; a brief mobility evaluation dated 11/23/11, which stated beneficiary needs a scooter, has PVD, DDD and DJD and is unable to self-propel a wheelchair; physician’s letter dated 12/16/11, which indicated that a face-to-face exam was conducted for the beneficiary and that he has extensive cardiac history i.e.,: left ventricular hypertrophy, dilated right ventricle, dilated left and right atrium, mitral and tricuspid regurgitation, has a permanent pacemaker; RESNA-certificate; a seating evaluation; clinical noted with dates 01/18/12 and 03/08/12.
    • Missing – Authenticated face-to-face examination; objective documentation such as graded arm and leg strength; range of motion; gait and balance evaluation on the mobility evaluation; documentation on progression of ambulation difficulty overtime history of beneficiary’s mobility limitation which significantly impairs his the ability to participate in one or more MRADLs and that it cannot be sufficiently resolved by use of a cane, walker or manual wheelchair; that beneficiary does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to perform MRADLs, that he is able to safely transfer to and from a POV, is able to operate the tiller steering system and has the postural stability and position as well and the mental capabilities to operate the POV in the home; physician’s oversight of beneficiary’s condition; clinical notes supporting the continued use of the POV.

K0823-RR-KJ – Power wheelchair, group 2 standard, captain’s chair

Date of Service: 08/14/12

    • Received – 7-element order dated 3/22/12; detailed product description dated 04/05/12; proof of delivery dated 05/14/12; home Assessment dated 04/05/12; mobility evaluation dated 03/22/12 which stated beneficiary has severe rheumatoid arthritis, had a Jazzy PWC 10 years ago; movements noted as “somewhat shaky,” upper extremities strength “diffusely in the 4- to 4 range” with significant pain attempting any kind of greater resistance, has minimal active movement in her lower extremities, and has a manual wheelchair for transport.
    •  Missing – Documentation to support sufficient objective arm and leg strength and range of motion; documentation on progression of ambulation difficulty overtime, history of mobility limitation that significantly impairs the beneficiary’s ability to participate in 1 or more MRADLs, what has changed that she now requires a PWC, and why an optimally-configured manual wheelchair or POV would not meet her mobility needs; records to support beneficiary’s weight is less than or equal to the weight capacity of the power wheelchair provide; physician’s oversight of beneficiary’s condition; clinical notes supporting the continued use of the PWC.

  1. Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea – LCD L11528

    E0562-RR-KX – Humidifier, heated, used w/ PAP device

    Date of Service: 05/28/12

    • Received – Order for billed item dated 07/31/12; CPAP “replace” order dated 12/27/11; sleep study dated 08/23/04 that is not signed; progress note dated 12/21/11 supporting use; an overnight recording sheet; an order for billed item dated 05/30/12 and signed 06/29/12.
    • Missing – Valid order that is signed and dated prior to the claim submission; face-to-face clinical re-evaluation by the treating physician with documentation that symptoms of obstructive sleep apnea are improved; documentation supporting objective evidence of adherence to use of the PAP device reviewed by the treating physician; clinical documentation supporting continued need and medical management; treating physician’s face-to-face clinical evaluation prior to sleep study.

E0601-RR-KJ – Continuous airway pressure (CPAP) device

Date of Service: 04/20/12

E0601-RR-KJ – Continuous airway pressure (CPAP) device

Date of Service: 05/20/12

    • Received – Instruction checklist; VNA Home Care Services form for 05/25/11; physician’s order for CPAP; initial and titration polysomnogram reports; recertification of positive airway pressure device.
    • Missing – Treating physician’s face-to-face evaluation of the beneficiary prior to the sleep study documenting symptoms of obstructive sleep apnea; treating physician’s face-to-face re-evaluation of beneficiary documenting that symptoms of sleep apnea have improved; documentation supporting objective evidence of adherence to the use of the PAP device reviewed by the treating physician; documentation to support ongoing medical management of the condition for which the CPAP device is ordered.

  1. Parenteral Nutrition – LCD L5063

    B4185 – Parenteral nutrition solution, per 10 grams lipids

    # of units billed = 4

    Date of Service: 12/26/11 to 01/01/12

    • Received – DIF signed by the supplier with no correlating physician order; delivery information for TPN for dates other than the billed DOS; lab reports; Home Health Certification and POC signed by Dr.; Home Infusion verbal order signed by the RN and RPH with start date of 12/05/11; TPN prescription signed by the Pharm D dated 12/02/11; unauthenticated skilled nursing visit notes dated 01/05/12 and 12/29/11.
    • Missing – Copy of the treating physician’s detailed written, signed, and dated order; copy of the revised DME Information Form (DIF) signed and dated by the supplier; treating physician’s clinical record documentation supporting that the beneficiary has a permanent, severe pathology of the alimentary tract which does not allow absorption of sufficient nutrients to maintain weight, strength commensurate with the patient’s general condition, a condition involving the small intestine and/or it’s exocrine glands which significantly impairs the absorption of nutrients, or disease of the stomach and/or intestine which is a motility disorder and impairs the ability of nutrients to be transported through the GI system; documentation supporting the continued need and use of the billed lipids.

B4224 – Parenteral nutrition administration kit, per day

# of units billed = 7

B4220 – Parenteral nutrition supply kit; premix, per day

# of units billed = 7

B4197 – Parenteral nutrition solution, compounded amino acid & carbohydrates w/ electrolytes, trace elements & vitamins, including prep, any strength, 74 to 100 gm of protein – premix

# of units billed = 7

B4185 – Parenteral nutrition solution, per 10 grams lipids

# of units billed = 18

Date of Service: 04/20/12 to 04/26/12

    • Received – Prescription signed and dated 06/23/11; electronic prescription data; delivery information; prescription dated 02/02/12; multiple delivery tickets; DIF dated 02/07/12; progress note that supports the beneficiary’s condition of “short gut syndrome;” discharge summary dated 04/20/12; medication profile; cardiac strips; admission orders; multiple hospital records including labs and diagnostics.
    • Missing – Order for the kits (the kit and premix kit are both missing from the DIF); documentation supporting that the beneficiary cannot be maintained on oral or enteral feedings due to severe pathology and must have IV infused nutrients; fecal fat test results; documentation of significant malnourishment and has very severe fat malabsorption, or significant malnourishment and has a severe motility disturbance of small intestine and/or stomach unresponsive to prokinetic medication (includes date and dosage) demonstrated by either: a) Scintigraphically; or b) barium or radiopaque pellets fail to reach the right colon by 6 hours following administration, has a disease and clinical condition that has been documented as being present with no response to altering the manner of delivery of appropriate nutrients and, results of any small bowel motility study; list of medications the patient was on at the time of the test.

  1. Enteral Nutrition – LCD L5041

    B4150 – Enteral formula, nutritionally complete with intact nutrients

    # of units billed = 558

    B4035 – Enteral feeding supply kit; pump fed, per day

    # of units billed = 31

    Date of Service: 03/01/12 to 03/31/12

    • Received – DIF dated 03/31/12; packing slip; physician order; x-ray report; multiple nursing facility dietary notes; nursing progress notes dated 11/21/11 through 03/15/12 that support the beneficiary had a G-tube by which enteral formulas was administered as a result of persistent dysphasia with risk of aspiration and weight loss; progress notes support the beneficiary was in fact a hospice patient on the billed date of service (the need for enteral feedings is related to the reason the Hospice benefit was elected); a note that states in part, ‘Upon review of the documentation, it was determined that we inadvertently billed incorrectly for the enteral nutrition supplies for the month of March 2012. Upon further investigation it was determined (the beneficiary) was in an active Hospice stay, During the time period in question, (the beneficiary) was under hospice care and should not have been billed. Please find an updated Invoice/Claim attached which will show a $0 balance.’
    • Missing – Treating physician’s medical records supporting the need for enteral nutrition and that the patient has a permanent impairment, either non-function or disease of the structures that normally permit food to reach the small bowel; documentation supporting that the patient requires an enteral pump because gravity feeding is not satisfactory due to reflux and/or aspiration, severe diarrhea, dumping syndrome, administration rate less than 100 ml/hr, blood glucose fluctuations, circulatory overload, gastrostomy/jejunostomy tube used for feeding.

B4035 – Enteral feeding supply kit; pump fed, per day

# of units billed = 30

A6402-A1 – Gauze, non-impregnated, sterile, pad size 16sq or less than, without adhesive border, each dressing

# of units billed = 50

B4154 – Enteral formula, nutritionally complete, for special metabolic needs; excludes inherited diseases

# of units billed = 450

Date of Service: 06/01/12 to 06/30/12

    • Received – Physician’s Order for Glucerna 1.5, 1485 cal/day (missing the route of administration); unauthenticated order for syringes; Supplier’s DIF; Registered Dietician’s evaluation dated 07/09/12 indicating NPO, on tube feeds @ 55ml/hr x 18 hours; progress note dated 08/01/12 indicating a g-tube placed secondary to dysphagia in 12/2009 and recurrent aspiration pneumonia; unauthenticated personal information sheet.
    • Missing – Detailed physician’s order for the enteral nutrition which includes the route of administration, feeding supply kits for the pump, and the pump.


  • Medicare requires that all documentation must be dated, and must be able to authenticate the author with a valid handwritten or electronically signed signature. Please refer to the Supplier Manual for guidance on signature requirements: http://www.medicarenhic.com/dme/supmandownload.aspx


  • Suppliers have appeal rights on claims denied as a result of a CERT audit. A redetermination request may be submitted following the same guidelines as any other redetermination request. However, the supplier must identify the appeal case as a CERT case. If the supplier is using the “Medicare Redetermination Request Form”, be sure to mark:
    • “Overpayment Appeal” as “Yes”
    • “If yes, who requested overpayment” as “CERT”
    • And to also include the CERT CID# in the Reasons/Rationale section.

The form may be accessed here: CMN and Forms

If the supplier is using their own redetermination request form, please identify the appeal case as a CERT case by including verbiage, such as: “This is a CERT case” and be sure to include the CERT CID#.