CMRS (ACAC) case studies
CMRS · Put your knowledge to work in context.
The Certified Medical Review Specialist (CMRS) credential is aimed at professionals who review medical records for accuracy, compliance, and appropriate reimbursement - typically coders, auditors, clinical documentation specialists, utilization reviewers, and compliance staff moving into a review-focused role. The exam tests whether you can look at documentation and reach a defensible conclusion: is the record complete, does the code match the documentation, was the service medically necessary, and does the claim meet payer and regulatory requirements. The CMRS case studies are 5 cases and about 2,126 words.
1The Sepsis Query and the Missing Progress Note
A 64-year-old admitted with pneumonia has an admission note documenting 'sepsis, lactate 3.1, started on broad-spectrum antibiotics within 1 hour.' Day 2 progress notes document 'improving, afebrile, tolerating PO.' The physician documented 'pneumonia, resolved sepsis' on the discharge summary. The CDI specialist wants to query for 'severe sepsis' because the lactate was 3.1 and the patient received IV antibiotics.
504 words, about 3 min2The Overlapping E/M and Procedure on the Same Day
An auditor reviews 20 charts from a family medicine clinic. One chart shows a 99214 (established patient, moderate complexity) billed with a 20610 (arthrocentesis, major joint) on the same date.
410 words, about 2 min3The Sampling Plan That Missed the Risk
A compliance auditor must audit outpatient claims for a multi-site physician group with 40,000 claims/year across 6 sites. Last year's audit used a random sample of 60 claims and found a 4% error rate.
410 words, about 2 min4The Whistleblower and the Retaliation Risk
A billing specialist reports to the compliance officer that a manager instructed staff to 'always bill 99215 for Medicare patients' and to 'add modifier 59 when claims deny.' The specialist is the only person who raised the issue and asks to remain anonymous. The compliance officer confirms the manager's instruction occurred.
395 words, about 2 min5The Copy-Forward Progress Note
An auditor reviews a 5-day inpatient stay for a patient with COPD exacerbation. The progress notes for days 2–5 are nearly identical, including the same vital signs, the same exam findings, and the same assessment.
407 words, about 2 min