CMRE cheat sheet

Medical review applies coverage, coding, and clinical criteria to claims and records; it is distinct from clinical care decisions and does not create a treating relationship.

Medicare coverage rests on three gates: a statutory benefit category, a national or local coverage determination, and documentation showing the item or service was reasonable and necessary.

National Coverage Determinations bind all Medicare contractors; Local Coverage Determinations bind only the jurisdiction of the issuing MAC and cannot contradict an NCD.

The Social Security Act sections 1862 (exclusions) and 1861 (definitions of covered services) anchor most Medicare medical review authority.

HIPAA Privacy Rule permits disclosure to health plans for payment without patient authorization; the minimum necessary standard applies to routine reviews.

Recovery Audit Contractor and Medicare Administrative Contractor reviews share the same appeal ladder: redetermination, reconsideration, ALJ hearing, Medicare Appeals Council, then federal district court.

A reviewer must confirm the beneficiary was eligible on the date of service, the provider was enrolled and in good standing, and the service was not statutorily excluded.

Clinical review determinations must be made by a reviewer with appropriate licensure and specialty credentials, documented in the file.

The record must support the who, what, when, where, why, and how: identity, service, date, setting, medical necessity rationale, and method.

Timeliness rules (for example, authentication of verbal orders and completion of operative reports) are conditions of participation and payment, not merely good practice.

A valid order requires the ordering practitioner's identity, the specific service, frequency or duration, and a signature; missing or late signatures are a common denial basis.

Documentation by exception (charting only abnormalities) is acceptable only where facility policy defines normal findings and the policy is retrievable.

Copy-and-paste and cloned documentation undermine credibility; reviewers check for internal inconsistency, identical notes across dates, and mismatched clinical detail.

Amendments must be dated, timed, signed, and traceable; late entries are permitted but must be labeled as late; erasures and backdating are prohibited.

For evaluation and management services, the record must support the level selected under the applicable framework, including history, examination, and medical decision making or time.

Missing documentation is treated as no service rendered in audit and appeal contexts; the reviewer cannot assume facts not in the record.

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

The principal diagnosis is the condition established after study to be chiefly responsible for the admission; the first-listed diagnosis on outpatient claims is the reason for the encounter.

Present on admission indicators apply to inpatient claims: Y, N, U, W, and E; hospital-acquired conditions with POA N can trigger payment reduction.

Modifiers convey that a service was altered; modifier 25 marks a significant, separately identifiable E/M service on the same day as a procedure.

The National Correct Coding Initiative edits define code pairs that cannot be billed together; modifier 59 or the X modifiers may override only when the clinical circumstances support separate services.

Global surgical packages include preoperative, intraoperative, and postoperative care; a return to the operating room for a related complication during the global period generally is not separately payable.

National Correct Coding Initiative and Medically Unlikely Edits are automated; clinical review of claim lines focuses on units, bundling, and medical necessity.

Claim review checks the five R's: right patient, right code, right modifier, right units, and right date of service.

Medical necessity means the service is reasonable, necessary, and appropriate for the diagnosis, symptoms, and stage of treatment, and no less costly alternative is adequate.

InterQual and Milliman Care Guidelines are proprietary criteria sets; they inform but do not replace the reviewer's clinical judgment or the plan's written policy.

Observation status is an outpatient service; a patient in observation has no inpatient Part A coverage and may face different cost sharing and skilled nursing facility eligibility.

The two-midnight rule presumes inpatient admission is appropriate when the physician expects a stay spanning two midnights; shorter stays require documentation of an exception.

Concurrent review identifies continued-stay necessity; discharge planning review identifies safe transition and avoids avoidable readmission.

Peer-to-peer review allows the ordering or attending physician to discuss the case with the reviewing physician before a final adverse determination.

An adverse determination requires a written notice with the specific reason, the criteria used, and appeal rights, delivered within regulatory timeframes.

Retrospective review applies the same criteria as prospective review but must consider information available at the time of service, not later developments.

Quality review evaluates whether care met accepted standards, including timeliness, appropriateness, safety, and coordination, independent of payment.

Never events, such as wrong-site surgery and retained foreign bodies, are serious reportable events that trigger mandatory review and often nonpayment.

Hospital-acquired conditions with present-on-admission indicator N are candidates for payment reduction under the Medicare HAC program.

The Agency for Healthcare Research and Quality patient safety indicators and the Centers for Medicare & Medicaid Services hospital-acquired condition measures are common screening tools.

Root cause analysis identifies system failures behind a sentinel event; the focus is process correction, not individual blame.

Peer review protections vary by state; the reviewer must know whether the work product is privileged and avoid improper disclosure.

Mortality and morbidity review compares expected with observed outcomes using risk adjustment; unadjusted comparisons can mislead.

Patient safety events must be reported through the facility's event reporting system and, where required, to accrediting or state bodies within stated timeframes.

Fraud is intentional deception for gain; waste is misuse of resources without intent; abuse is conduct inconsistent with sound business or clinical practice that causes unnecessary cost.

The False Claims Act imposes liability for knowingly submitting false claims; the qui tam provision allows private relators to sue on the government's behalf and share recoveries.

The Anti-Kickback Statute prohibits remuneration for referrals of federally payable items or services; intent is required and safe harbors provide protection.

The physician self-referral law (Stark) is a strict-liability civil statute barring certain designated health service referrals when a financial relationship exists, absent an exception.

The Civil Monetary Penalties Law and the Exclusion Statute authorize penalties and program exclusion; excluded providers' claims are not payable.

Red flags include services never rendered, upcoding, unbundling, duplicate claims, services on dates of death, and beneficiaries who deny receiving the service.

An effective compliance program includes written policies, a compliance officer, training, monitoring and auditing, and a nonretaliatory reporting mechanism.

Overpayments must be reported and returned within 60 days of identification under the Affordable Care Act; retaining a known overpayment creates False Claims Act exposure.

A grievance is an expression of dissatisfaction about the plan or provider, while an appeal is a request to reconsider an adverse benefit determination.

Medicare Advantage organization determinations are appealed first through plan reconsideration, then Independent Review Entity, ALJ, Medicare Appeals Council, and federal court.

Expedited appeals apply when the standard timeframe could seriously jeopardize life, health, or ability to regain maximum function; the plan must decide within 72 hours.

Original Medicare redetermination is filed with the MAC within 120 days of the initial determination; reconsideration follows within 180 days of the redetermination.

For an ALJ hearing, the amount in controversy must meet the annually adjusted threshold; the request must be filed within 60 days of the reconsideration.

The appeal record must include the denial letter, the specific criteria applied, the clinical documentation, and the physician's rationale for medical necessity.

Denials management tracks denial categories (eligibility, authorization, coding, medical necessity) and routes each to the correct correction or appeal pathway.

Timely filing deadlines are jurisdictional; missing them generally forfeits the appeal unless good cause is established.

Reviewers must apply criteria consistently, disclose conflicts of interest, and recuse from cases involving their own financial or personal relationships.

Confidentiality obligations under HIPAA and state law continue after employment ends; minimum necessary access applies to every record lookup.

A reviewer may not change a code or approve a service without documentation support; pressure to meet productivity or denial targets is not a defensible rationale.

Whistleblower protections under the False Claims Act and similar statutes prohibit retaliation against employees who report suspected fraud.

The compliance officer role is independent of revenue cycle operations; the compliance committee reports to the governing body.

Professional conduct requires accurate time and credential reporting, honest audit findings, and no alteration of records after an audit request.

Gifts, meals, and consulting arrangements with vendors or referral sources must comply with the organization's conflict-of-interest and anti-kickback policies.

Ethical review decisions should be documented with the criteria, the evidence weighed, and the rationale, so they can withstand independent scrutiny.