CMR cheat sheet

Medicare coverage rests on two statutory pillars: a benefit category exists (Social Security Act) and the item or service is reasonable and necessary for diagnosis or treatment.

National Coverage Determinations (NCDs) bind all Medicare contractors; Local Coverage Determinations (LCDs) bind only the MAC jurisdiction that issued them.

An LCD may not restrict coverage more than an NCD; when they conflict, the NCD controls.

HIPAA Privacy Rule permits disclosure of protected health information for treatment, payment, and health care operations without patient authorization.

The minimum necessary standard applies to uses and disclosures except treatment and disclosures to the patient or authorized by the patient.

EMTALA requires a medical screening examination and stabilizing treatment for anyone presenting to an emergency department, regardless of insurance or ability to pay.

Conditions of Participation are the minimum health and safety standards a provider must meet to receive Medicare payment.

Recovery Audit Contractor (RAC) reviews target improper payments; MACs handle claims processing and medical review in their jurisdiction.

The medical record must support the diagnosis, justify the treatment, and document the patient's response to care.

Documentation is considered late when not completed by the timeframe set in medical staff bylaws (commonly 14-30 days).

A valid history and physical is generally required within 30 days before admission or 24 hours after admission for inpatient stays.

Only the author of an entry may amend it; late entries must be clearly labeled, dated, and timed.

Authentication requires a legible identifier (written or electronic signature); a signature stamp is not acceptable.

Cloned documentation (identical text across records) is a compliance red flag and may support denial or fraud referral.

Missing documentation cannot be supplemented by verbal order or recollection after the fact for the date of service in question.

Objective elements such as vital signs, labs, and imaging must be documented to support the clinical impression.

ICD-10-CM codes diagnoses; ICD-10-PCS codes inpatient procedures; CPT and HCPCS Level II code outpatient services and supplies.

Code the highest level of specificity documented; unspecified codes are used only when documentation lacks detail.

Principal diagnosis is the condition established after study to be chiefly responsible for admission.

Evaluation and management level is determined by documented medical decision making or time, per current CPT guidance.

Modifier 25 reports a significant, separately identifiable E/M service on the same day as a procedure.

Modifier 59 (or X{EPSU} subsets) identifies distinct procedural services not normally reported together.

The National Correct Coding Initiative (NCCI) edits define code pairs that are not separately payable; a modifier may bypass only when clinically appropriate.

Clean claim rate is the percentage of claims accepted on first submission without edits or rejection.

Medical necessity is determined by matching documented clinical findings against coverage criteria (NCD, LCD, or InterQual/MCG).

InterQual and Milliman Care Guidelines are proprietary criteria sets; they inform but do not override Medicare coverage rules.

An observation stay is an outpatient status; it does not count toward the three-day inpatient prospective payment system (IPPS) stay requirement.

The two-midnight rule presumes inpatient status when a physician expects the stay to span two midnights.

Concurrent review occurs during the stay; retrospective review occurs after discharge and may result in denial and recoupment.

A condition code 44 allows a hospital to change inpatient to outpatient status before discharge when criteria are not met.

The admission review outcome options are certification, non-certification, or modification of the requested level of care.

Interrater reliability measures consistency of review determinations among reviewers using the same criteria.

The seven elements of an effective compliance program include written policies, a compliance officer, training, communication, monitoring, enforcement, and corrective action.

Sampling in audits must be statistically valid to extrapolate findings; non-random samples cannot support extrapolation.

An error rate is calculated as the number of erroneous units divided by total units reviewed.

Root cause analysis identifies underlying system failures rather than individual blame for adverse events.

A Plan-Do-Study-Act (PDSA) cycle is a structured quality improvement method for testing changes.

The OIG Work Plan lists audit and enforcement priorities and signals areas of heightened scrutiny.

Audit findings should be tracked to closure with documented corrective action plans and re-audit to confirm effectiveness.

Benchmarking compares performance metrics against internal or external standards to identify variation.

Fraud is intentional deception for gain; waste is misuse of resources without intent; abuse is practices inconsistent with sound business or medical standards.

The False Claims Act imposes liability for knowingly submitting false claims, with treble damages and per-claim penalties.

The Anti-Kickback Statute prohibits remuneration to induce referrals for items or services payable by federal health programs.

The Stark Law prohibits physician self-referral for designated health services unless an exception applies.

The Civil Monetary Penalties Law prohibits offering inducements to Medicare or Medicaid beneficiaries.

The Physician Payments Sunshine Act requires reporting of transfers of value to physicians and teaching hospitals.

Red flags include upcoding, unbundling, duplicate billing, services not rendered, and billing for medically unnecessary services.

The OIG Self-Disclosure Protocol allows providers to voluntarily report potential fraud and negotiate resolution.

Medicare Part A and B redetermination (first level) is filed with the MAC, generally within 120 days of the initial determination.

The five Medicare appeal levels are redetermination, reconsideration, ALJ hearing, Medicare Appeals Council, and federal district court.

Reconsideration is performed by a Qualified Independent Contractor (QIC), not the MAC that issued the redetermination.

The amount in controversy threshold must be met for ALJ and judicial review levels and is updated annually.

Peer review is evaluation of a clinician's care by professional peers of comparable training and scope.

Peer review protections under the Health Care Quality Improvement Act (HCQIA) require due process and reporting to the National Practitioner Data Bank.

An appeal must include the denial notice, the appeal request, and supporting clinical documentation demonstrating medical necessity.

Timely filing deadlines are jurisdictional and cannot be waived for good cause.

Reviewers must make determinations based on the clinical record and coverage criteria, not on the payer's financial interest.

Conflicts of interest must be disclosed and managed; a reviewer should recuse when a personal or financial relationship exists.

Patient information should be shared only on a need-to-know basis consistent with HIPAA.

Communication with providers about denials should cite the specific criterion or policy not met.

Informed consent requires disclosure of risks, benefits, alternatives, and the patient's voluntary agreement.

Documentation should be factual, objective, and free of disparaging or speculative language.

Whistleblower protections exist under federal law for reporting suspected fraud or unsafe care.

Reviewers must not alter, fabricate, or backdate documentation; such actions are reportable compliance violations.