CMS Defines Clinical Review Judgment Process

Clarifies Language in Program Integrity Manual

The Centers for Medicare & Medicaid (CMS) added a new Section (§ 3.14) regarding Clinical Review Judgement to the Medicare Program Integrity Manual. The new Section clarifies existing language regarding clinical review judgments, and also requires that Medicare claim review contractors

instruct their clinical review staff to use the clinical review judgment process when making complex review determinations about Medicare claims. The change request, CR 6954, is published as Transmittal 338 for the Medicare Program Integrity Manual, Publication 100-08. The implementation date for this new rule is June 15, 2010.

According to the new Section, Clinical Review Judgment (CRJ) now must involve two steps:

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

The change further stipulates that CRJ does not replace poor or inadequate medical records. Also, CRJ may not be used to override, supersede or disregard a policy requirement -- which include laws, regulations, CMS rulings, manual instructions, policy articles, national coverage decisions, and local coverage determinations.

CMS also published a MLN Matters article on the change.

Find the original Transmittal and MLN Matters article in our Documents Section.