(Medicare Program Integrity Manual)

Post-payment Review Requirements for MACs  The MAC shall make a review determination, and mail the review results notification letter to the provider within 60 calendar days of receiving the requested documentation.  For claims associated with any referrals to the UPIC for program integrity investigation, MACs shall stop counting the 60-day time period on the date the referral is made. The 60-day time period will be restarted on the date the MAC received requested input from the UPIC or is notified by the UPIC that the referral has been declined.   For claims sent to MR for reopening by the contractor appeals de partment, in accordance with Pub. 100-04, chapter 34, 10.3, begin counting the 60 days from the time the medical records are received in the MR department.   Post-payment Review Requirements for RACs  When a RAC receives requested documentation for review within 45 calendar days of the date of the ADR, the RAC shall do the following within 30 calendar days of receiving the requested documentation: 1) make and document the review determination, and 2) communicate the results to the provider.  State Laws that  Affect Prepayment Review Timeliness Requirements   The MACs shall adhere to state laws that require an evidentiary hearing for the beneficiary before any denials are processed. The MAC shall review the claim within 30 days, allow the time required for the evidentiary hearing, and then continue with the processing of the claim on the next business day.  Post-payment Review Requirements for UPICs  To promote the timeliness of the investigative process, the UPICs shall complete post-payment medical review and provide the lead investigator with a final summary of the medical review findings that includes reference to the allegations being substantiated/not substantiated by medical review, reasons for denials, and any observations or trends noted within 60 calendar days, unless otherwise directed by CMS. The counting for the 60-day time period begins when all of the documentation is received by the UPIC. The UPIC shall have a HIPAA compliant process to receive this documentation that includes the application of the date the documents are received at the UPICs designated mailing address for all methods described in section 3.2.3.5 of this chapter. The medical review unit shall communicate the medical review findings in a summary document to the investigative le ad within 60 calendar days of receiving all of the requested documentation. Medical review for the purpose of fraud, waste, or abuse requires 60 days to allow for the integration of information from the investigative process. This information may be a result of recent/concurrent investigative actions such as beneficiary/provider/supplier interviews, site visits and/or receipt of additional internal/external information.   If the UPIC is unable to complete the post-payment medical review in 60 days, they shal l document this and the reason for the delay in the UCM, and communicate this to their COR.   3.3.1.2 - Non-Medical Record Review  (Rev. 10365; Issued: 10-02- 20; Effective: 08 -27-20; Implementation: 08-27-20)  This section applies to MACs, SMRC, and UPICs, a s indicated.   A. Definition   Non-medical record reviews uses  manual intervention, but only to the extent a reviewer can make a determination based on information on a claim. It does not require clinical judgment in review of medical record documentation. Contractors shall only perform a non-medical record review fo r denials of related claims and/or no receipt of ADR documentation where such denials cannot be automated.  3.3.1.3 - Automated Review  (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  A. Definition   A medical review is considered automated when a payment decision is made at the system level, using available electronic information, with no manual intervention.  CERT refers to all reviews where no documentation was requested as T -claim review. T-claims are a particular category o f claim reviewed by CERT. T -claims are claims that were automatically denied by the MAC.  B. Basis for Automated  Reviews   The MAC, RAC, CERT, SMRC, and UPIC shall ensure that automated prepayment and postpayment denials are based on clear policy that serves as the basis for denial; or a Medically Unlikely Edit (MUE); or occurs when no timely response is received to an ADR.   When a clear policy exists (or in the case of a MUE), MACs, RACs, SMRC, and UPICs have the discretion to automatically deny the services without stopping the claim for manual review, even if documentation is attached or simultaneously submitted. Reviewers s hall still make a determination based on the liability limitations of 1879 of the Act. The term clear policy means a statute, regulation, NCD, coverage provision in an interpretive manual, coding guideline, LCD or MAC article that specifies the circumst ances under which a service will always be considered non- covered, incorrectly coded, or improperly billed.  A MUE is a unit of service (UOS) edit for a Healthcare Common Procedure Coding system (HCPCS)/Current Procedural Terminology (CPT) code for service s rendered by a single provider/supplier to a single beneficiary on the same date of service. The ideal MUE is the maximum UOS that would be reported for a HCPCS/CPT code on the vast majority of appropriately reported claims. The MUE program provides a met hod to report medically reasonable and necessary UOS in excess of a MUE.   Automated edits can be used for apparent typographical errors (e.g., 10,000 blood cultures for the same beneficiary on the same day).   MACs shall implement automated prepayment revie w whenever appropriate.   The RACs refer to all reviews where no documentation was requested as automated review.   3.3.2 - Medical Review Guidance  (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  This section applies to MACs, CERT, Recovery Auditors, and UPICs, as indicated.   This section describes the requirements that MACs, CERT, Recovery Auditors, and UPICs shall follow when reviewing submitted documentation. Additional requirements for UPICs are located in PIM chapter 4. When UPIC staff is performing benefit integrity reviews, their focus is different than that of MACs, CERT, and Recovery Auditors. For example, UPIC staff looks for some of the following situations when reviewing documentation:    Possible falsification or other evidence of alterations including, but not limited  to: obliterated sections; missing pages, inserted pages, white out; and excessive late entries;    Evidence that the service billed for was actually provided;  or,   Patterns and trends that may indicate potential fraud.   3.3.2.1 - Documents on Which to Base a Determination  (Rev. 802; Issued: 06- 22-18; Effective: 07 -24-18; Implementation: 07 -24-18)  This section applies to MACs, CERT, RACs, SMRC and UPICs, as indicated.   The MACs, CERT,  RACs, SMRC, and UPICs shall review any information necessary to make a prepayment and/or postpayment claim determination, unless otherwise directed in this manual. This includes reviewing any documentation submitted with the claim and any other documentat ion subsequently requested from the provider or other entity when necessary. In certain circumstances it may be appropriate for medical reviewers to consider relevant and accessible billing history or other information obtained from the Common Working File  (in limited circumstances), outcome assessment and information set (OASIS), or the minimum data set (MDS), among others. For Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corr oborate the documentation in the beneficiarys medical documentation and confirm that Medicare coverage criteria have been met.   3.3.2.1.1 - Progress Notes and Templates  (Rev. 833; Issued: 10- 12-18; Effective: 11 -13-18; Implementation: 11 -13-18)  A.  Definitions   For the purposes of Section 3.3.2.1.1, the following definitions apply:   1.  "Progress Notes"  -- visit notes, encounter notes, Evaluation and Management documentation, office notes, face -to-face evaluation notes or any other type of record of the services provided by a physician or other licensed/certified medical professional (LCMP) in the medica l record.  Progress notes may be in any form or format, hardcopy or electronic.    2.  "Template" -- a tool/instrument/interface that assists in documenting a progress note.  Templates may be paper or electronic.   Electronic records may involve any type of interface including but not limited to:  simple electronic documents,   sophisticated graphical user interfaces (GUIs) with clinical decision and documentation support prompts, or   electronic pen capture devices.   Licensed/Certified Medical Profession al (LCMP)  Medical professional licensed or certified to practice in the state in which services are rendered.  For the purposes of documenting DMEPOS items, the physician or LCMP must not have a financial relationship with the DMEPOS supplier.  B.  Guid elines Regarding Which Documents Review Contractors Will Consider  The review contractor shall consider all medical record entries made by physicians and LCMPs.  See PIM 3.3.2.5 regarding consideration of Amendments, Corrections and Delayed Entries in Medi cal Documentation.   The amount of necessary clinical information needed to demonstrate that all coverage and coding requirements are met will vary depending on the item/service.  See the applicable National and Local Coverage Determination for further deta ils.  CMS does not prohibit the use of templates to facilitate record -keeping.  CMS also does not endorse or approve any particular templates except for the clinical templates it publishes on its website.  A physician/LCMP may choose any template to assist  in documenting medical information.  Contractors shall consider information captured in templates when conducting medical review.     Some templates provide limited options and/or space for the collection of information such as by using check boxes, predefined answers, limited space to enter information, etc.   CMS discourages the use of such templates.   Claim review experience shows that that limited space templates often fail to capture sufficient detailed clinical information to demonstrate that all c overage and coding requirements are met.    Physician/LCMPs should be aware that templates designed to gather selected  information focused primarily for reimbursement purposes are often insufficient to demonstrate that all coverage and coding requirements are met.  This is often because these documents generally do not provide sufficient information to adequately show that the medical necessity criteria for the item/service are met.    If a physician/LCMP chooses to use a template during the patient visit, CMS encourages them to  select one that allows for a full and complete collection of information  to demonstrate that the applicable coverage and coding criteria are met.   Certificates of Medical Necessity (CMN), DME Information Forms (DIF), supplier prepared statements and physician attestations by themselves do NOT provide sufficient documentation of medical necessity, even if signed by the signed by the ordering physician..  See PIM 5.7 for additional information on documentation.  C.  Financial Li ability   The physician/LCMP should be aware that inadequate medical record documentation can lead to a financial liability for the Beneficiary and/or Supplier, should the reviewer determine that a claim is not supported.   In addition, the physician/LCMP should be aware that when ordering an item or service that will be furnished by another entity, Section 1842(p)(4) of the Social Security Act requires that adequate documentation supporting medical necessity be provided to the entity at the time that the item or service is ordered. Physicians/LCMPs who fail submit documentation upon a supplier's request may trigger increased MAC or RAC review of the physician/LCMP's evaluation and management services.   3.3.2.1.2  DMEPOS Orders  (Rev. 10190; Issued: 06-19-2020, Effective: 01 -01-2020; Implementation: 07-01-2020)  Totality of the Record  All DMEPOS items require a Standard Written Order (SWO) from the treating practitioner as a condition of payment. Medicare contractors shall consider the totality of the medical r ecord when reviewing for compliance of the SWO elements. This will allow contractors to account for the dynamic nature of electronic medical record documentation systems, and give them additional discretion when they believe the entirety of the record demo nstrates compliance with our order requirements. For example, a contractor may nonetheless support payment when an order has a missing or flawed element that is clearly documented elsewhere in the record.   Contractors acting as a secondary reviewer shall g rant deference to the initial reviewers discretion, if such an initial decision resulted in a reasonably prudent decision that aligns with Medicare coverage and coding instructions.  3.3.2.2 - Absolute Words and Prerequisite Therapies  (Rev. 10365; Issued: 10 -02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  This section applies to MACs, CERT, Recovery Auditors, and UPICs, as indicated.