CMS Mandated Edits

3.5.3 - CMS Mandated Edits (Rev. 721; Issued: 06-09-17; Effective: 07-11-17; Implementation: 07-11-17) In past years, CMS created mandated edits that suspend certain claims for medical review coverage and coding review. However, more recently, CMS has given the contractors the discretion to prioritize workload to effectively lower the error rate. CMS is now in the process of removing such mandated coverage and coding review edits from CWF, pricer, grouper, fee schedules, etc. Contractors may override CMS mandated edits that suspend for medical review coverage and coding review without performing review if one or more of the following conditions apply: 1. The contractor does not have MR responsibility for the claim, or 2. The contractor's data analysis/priority setting/ MR strategy does not indicate this service is a problem in their jurisdiction, or 3. It is not a skilled nursing facility (excluding swing beds) or a home health demand bill (these demand bills must be reviewed).