On May 14, 2010, the Centers for Medicare and Medicaid Services (CMS) released an MLN Matters article explaining Change Request (CR) 6954. CR 6954 adds Section 3.14 to the Medicare Program Integrity Manual. This section clarifies language regarding clinical review judgments. It requires Medicare claim review contractors to instruct their clinical review staffs to use the clinical review judgment process when making complex review determinations about a claim. The clinical review judgment involves two steps:
(1) The synthesis of all medical record information to create a longitudinal clinical picture of the patient; and
(2) The application of the clinical picture to the review criterial to determine whether the clinical requirements in the relevant policy are met.
This information may be helpful for providers in appealing audits, for example, where one note does not support medical necessity on its own, but where the totality of the medical records establishes medical necessity.
For more information, please visit www.wachler.com or contact a Wachler & Associates attorney at 248-544-0888.