Policies and Guidelines Applied During Review

3.3 – Policies and Guidelines Applied During Review (Rev. 13008; Issued: 12-18-24; Effective: 01-17-25; Implementation: 01-17-25) This section applies to MACs, CERT, RACs, Supplemental Medical Review Contractors (SMRC) and UPICs, as indicated. A. Statutes, Regulations, the CMS’ Rulings, National Coverage Determinations, Coverage Provisions in Interpretive Medicare Manuals, and Local Coverage Determinations The primary authority for all coverage provisions and subsequent policies is the Social Security Act. In general, MACs, CERT, RACs, SMRC, and UPICs shall apply the provisions of the Act according to the following hierarchy of documents in effect at the time the item(s) or service(s) was provided to make medical review decisions: Social Security Act Code of Federal Regulations CMS’ Rulings National Coverage Determination (NCDs) Coverage provisions in Interpretive Manuals or Internet Only Manuals (IOM) which includes Medical Review Guidance in the Medicare Program Integrity Manual CMS coding policies Technical Direction Letters (TDLs)* The relevant MAC’s Local Coverage Determination (LCDs) The relevant MAC’s local articles AHA Coding Clinics. *TDLs that contain MR guidance may provide an exception to this hierarchy. B. Coding Guidelines The MACs, CERT, RACs, SMRC, and UPICs shall apply coding guidelines to services selected for review. All contractors shall determine that an item/service is correctly coded when it meets all the coding guidelines listed in the Current Procedural Terminology (CPT) book, International Classification of Diseases Guidelines (ICD), CMS HCPCS or ICD policy or guideline requirements, LCDs, or MAC articles. C. Internal Medical Review Guidelines The MAC, CERT, RACs, SMRC, and UPIC staffs have the discretion to develop detailed written review guidelines to guide staff during claim reviews. Internal MR guidelines shall specify the information to be reviewed by reviewers and the appropriate resulting determination. RACs are required to develop written review guidelines in accordance with their SOW. The MACs, CERT, RACs, SMRC, and UPICs shall make their internal MR guidelines available to their staff, as needed. Internal MR Guidelines shall not create or change the CMS policy.