Clinical Review Judgement - Resources

Here is the relevant text in the Change:

3.14 - Clinical Review Judgment (CRJ)

(Rev. 338, Issued: 05-14-10, Effective: 04-23-10, Implementation: 06-15-10)

A. Contractors to Which This Section Applies

This section applies to ACs, MACs, CERT, RACs, PSCs, and ZPICs, as indicated below.

B. General

The CRJ involves two steps: (1) the synthesis of all submitted medical record information (e.g., progress notes, diagnostic findings, medications, nursing notes) to create a longitudinal clinical picture of the patient, and (2) the application of this clinical picture to the review criteria to make a reviewer determination on whether the clinical requirements in the relevant policy have been met. AC, MAC, CERT, RAC, PSC, and ZPIC clinical review staff shall use CRJ when making complex review determinations about a claim.

The CRJ does not replace poor or inadequate medical records. CRJ by definition is not a process that ACs, MACs, CERT, RACs, PSCs and ZPICs can use to override, supersede or disregard a policy requirement. Policies include laws, regulations, CMS rulings, manual instructions, policy articles, national coverage decisions, and local coverage determinations.

Effective Date: April 23, 2010; Implementation Date: June 15, 2010

End of text.

The following links provide the original documents from the CMS website:

• CR 6954
  
  
• MLN Matters Article