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CMS Issues Two New Change Requests for Medical Review

Posted on Monday, October 29, 2018 12:21 PM

CMS recently issued two Change Requests (CR) related to medical review.  CR 10930 updates the Medicare Program Integrity Manual to clarify that CMS does not prohibit the use of templates to facilitate record-keeping. However, CMS does not endorse or approve any templates except for the clinical templates it publishes on its website. A physician may choose any template to assist in documenting medical information. Contractors shall consider information captured in templates when conducting medical review.

The National Association for Home Care & Hospice (NAHC) sought clarification from CMS on the implication of the CR for home health providers in light of CMS’ efforts to forward home health templates for the face-to-face encounter and the plan of care. NAHC specifically requested clarification regarding incomplete templates in relation to claim denials. Below is CMS’ response.

“This change request does not fundamentally change the way review contractors review templates. It clarifies that CMS endorses our own templates as the Program Integrity Manual (PIM) previously stated we didn’t endorse or approve any templates. It also reminds review contractors they must review the information contained in templates along with any other documentation they receive in response to an additional documentation request. Review contractors will use their discretion when determining if information captured in a template is sufficient to meet Medicare payment, coverage and coding policy. As the PIM currently describes, there are many types of templates. Some may encourage sufficient information/documentation, while others may not. For example, if a face to face visit is required and the date of the face to face visit is simply noted in a template, we would expect additional documentation of the visit in the medical records. However, if the practitioner has chosen to use a template and sufficiently documented the visit in the template, we would not expect duplicative documentation in another format.”

CMS also issued CR 10963 which clarifies that One-on-one education can be conducted based on reviews done by the Medicare Administrative Contractors, Recovery Audit Contractors or Supplemental Medical Review Contractor and that for Targeted Probe and Educate (TPE), TPE specific reporting letters shall not be considered or reported as one on one education.

CMS wants contractors to know that One-on-one education is intended to reduce the paid claims error rate by notifying, either in writing or orally, the individual billing entities of review findings identified on specific claims or a group of claims.

Source: NAHC Report

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