Medicare audits take several different forms (MACs, RACs, etc), but most of the rules are specified in Chapter 3 of an online Program Integrity Manual. CMS has issued some updates on December 18:
https://www.cms.gov/medicare/regulations-guidance/transmittals/2024-transmittals/r13008pi
It's called CR13735, T13008.
While most of the rules are unchanged, a few that are updated or if particular special interest are highlighted below.
- Legal Authority to Audit Documents - 3.2.3.B
- Third-Party Documents (e.g. audited lab is one party, ordering physician is a second party) - 3.2.3.3
- (The lab is the first party, CMS is the second party, and an imaging center that holds a supporting MRI record is a "third party.")
- Credentials of reviewers - 3.3.1.1.C
- 3.3.1.1.B, Clinical review involves two steps, synthesis of all the submitted records, and, then, application "of this clinical picture" to review criteria [eg LCDs].
- Automated Edits that Deny (LCDs, NCDs, MUE, etc) - 3.3.1.3.B
- Special Rules for Psychotherapy notes - 3.3.2.6
- Special Rules for (Physical) Therapy - 3.3.2.7
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| Records held by third-parties |
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| Basis of auto denials |
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Recall in May 2024, MolDx issued an article noting that lab requisition forms are "part of the medical record" which I believe means that information attested and signed on a lab requisition form does not need to be backed up (duplicated) by an earlier original medical chart record of the same fact. E.g. I think that MolDx means, if the lab form says the patient has metastatic breast cancer, that IS a valid medical record, and the auditor ought not demand an earlier medical record document like an MRI report.
