Revenue Cycle

CMS posts additional guidance regarding complex review

Recovery Auditor Report, May 27, 2010

A recently released transmittal from CMS adds direct language to the Medicare Program Integrity Manual that directs the AC, MAC, CERT, RAC, PSC and ZPIC clinical review staff to use clinical review judgment when making complex review determinations about a claim.

Clinical review judgment by definition is not a process that ACs, MACs, CERT, RACs, PSCs and ZPICs can use to override, supersede or disregard a policy requirement.

The link for can be found here.

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