Corporate Compliance

Transmittals and MLN Matters articles: CMS issues guidance on "clinical review judgment" to RACs and other auditors

Medicare Insider, May 25, 2010

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CMS instructs on "clinical review judgment"

On May 14, CMS issued a transmittal to define ?clinical review judgment? and instruct various contractors on its application. According to the new manual language, clinical review judgment involves two steps:

(1) the synthesis of all submitted medical record information (e.g., progress notes, diagnostic findings, medications, nursing notes) to create a longitudinal clinical picture of the patient, and (2) the application of this clinical picture to the review criteria to make a reviewer determination on whether the clinical requirements in the relevant policy have been met.

CMS also states that clinical review judgment does not replace poor or inadequate medical records, and cannot be used to override, supersede or disregard a policy requirement. CMS instructs contractors to use clinical review judgment when making a complex review determination about a claim.

Effective date: April 23, 2010
Implementation date: June 15, 2010

View the transmittal.

View a related MLN Matters article.



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