Medical review is a term for the process Medicare contractors use to examine data and request supporting documentation for claims submitted to Medicare. The goal of the medical review program is to reduce payment errors by identifying and addressing documentation and billing errors concerning coverage and coding made by providers. Access additional guidance regarding medical review through the following links:
Medical Review Articles and Resources
| Topic |
Publication Date |
| Appeals, Adjustments and the D9 Claim Change Reason (Condition) Code |
02.23.12 |
| Completion of Inpatient Lung Biopsy (Procedure Code 33.27) |
09.13.12 |
| Completion of Inpatient Service Specific Review of Short Stays Diagnosis Related Group (DRG) for Septicemia (DRG Codes 870, 871 and 872) |
05.22.12 |
| Complex Medical Review of Cellulitis without MCC (MS Diagnosis Related Group [DRG] 603) Short Stay Dates of Service |
07.23.12 |
| Complex Medical Review of Circulatory Disorders Diagnosis Related Group (DRG 287) |
07.23.12 |
| Complex Medical Review of Excisional Debridement (Procedure Code 86.22) |
11.14.12 |
| Complex Medical Review of Kidney & Urinary Tract Infections Without MCC: Diagnosis Related Group (DRG) 690 |
10.05.12 |
| Complex Medical Review of Kidney and Urinary Tract Infections Without MCC: Diagnosis Related Group (DRG) 690 |
10.11.12 |
| Complex Medical Review of Outpatient Cardiac Rehabilitation with Continuous ECG Monitoring (93798) |
05.31.12 |
| Complex Medical Review of Outpatient Pulmonary Rehabilitation, Including Exercise (Includes Monitoring), One Hour, Therapeutic, Prophylactic or Diagnostic (G0424) |
07.30.12 |
| Complex Medical Review of Outpatient Pulmonary Rehabilitation, Including Exercise (Includes Monitoring), One Hour, Therapeutic, Prophylactic or Diagnostic (G0424) |
08.02.12 |
| Complex Medical Review of Syncope & Collapse Diagnosis Related Group Diagnosis Related Group (DRG) 312 |
10.08.12 |
| Coverage and Claim Submission for Positron Emission Tomography (PET) Scans |
02.15.13 |
| Dual Chamber Pacemakers |
03.08.13 |
| Electronic Medical Record Tips |
09.06.12 |
| Entries in Medical Records: Amendments, Corrections, and Addenda |
12.26.12 |
| Humanitarian Use Device (HUD) Coverage |
12.14.12 |
| Inpatient Closed Endoscopic Biopsy of Lung: Results of Probe Medical Review |
10.08.12 |
| Inpatient Closed Endoscopic Biopsy of Lung: Results of Probe Medical Review |
10.08.12 |
| Inpatient Hospital Services: Top Denial Reason Codes for Medical Review, October-December 2012 |
02.27.13 |
| Inpatient Service Specific Complex Review of Short Stay Diagnosis Related Group (DRG) for Cardiac Arrhythmia (DRG Codes 308, 309 and 310) |
05.31.12 |
| Inpatient Service Specific Complex Review of Short Stays Diagnosis Related Group (DRG) for Chest Pain and Atherosclerosis (DRG Codes 302, 303 and 313) |
06.20.12 |
| Inpatient Service Specific Complex Review of Short Stays Diagnosis Related Group (DRG) for Esophagitis Gastroenteritis (DRG Codes 391 and 392) |
05.31.12 |
| Inpatient Service Specific Complex Review of Short Stays Diagnosis Related Group (DRG) for Nutritional Metabolic (DRG Codes 640 and 641) |
06.20.12 |
| Inpatient Service Specific Probe Review of Short Stays (less than Three Days) for Excisional Debridement (Procedure Code 86.22) |
02.15.12 |
| Inpatient Service Specific Review of Short Stays Diagnosis Related Group (DRG) for Heart Failure and Shock without CC/MCC (DRG 293) |
07.23.12 |
| Inpatient Service Specific Review of Short Stays Diagnosis Related Group (DRG) for Percutaneous Cardiovascular Procedure without Coronary Artery Stent without MCC (DRG 251) |
07.23.12 |
| Inpatient Service Specific Review of Short Stay DRGs for Two-Day Stay for Cardiac Arrhythmia (DRG Codes 308, 309 and 310) |
01.03.12 |
| Inpatient Service Specific Review of Short Stays DRGs for Percutaneous Transluminal Coronary Angioplasty (PTCA) with Stent (DRG Codes 246, 247, 248 and 249) |
01.03.12 |
| Inpatient Service-specific Probe Review of Permanent Cardiac Pacemaker Implants: Results of Probe Medical Review |
10.08.12 |
| Inpatient Service-specific Probe Review of Permanent Cardiac Pacemaker Implants: Results of Probe Medical Review |
10.08.12 |
| Isolated Ultrafiltration for Management of Fluid Overload in Cardiac Disease |
05.01.13 |
| Manual Medical Review of Therapy Services |
10.08.12 |
| Medical Review Part A Fact Sheet |
09.26.11 |
| Medical Review Progressive Corrective Action (PCA) Process |
09.26.11 |
| Medical Review Skilled Nursing Facility (SNF) Fact Sheet |
09.26.11 |
| Medicare Medical Records: Signature Requirements, Acceptable and Unacceptable Practices |
02.23.12 |
| Outpatient Hospital Services: Top Denial Reason Codes for Medical Review, October-December 2012 |
02.27.13 |
| Outpatient Pulmonary Rehabilitation (HCPCS G0424): Complex Medical Review |
04.23.13 |
| Overpayments Identified by the OIG: Extracorporeal Photopheresis, Add-On Codes, and Hospice-related Services |
05.08.13 |
| Probe Edit Medical Review of Percutaneous Transluminal Coronary Angioplasty (PTCA) with Stent, Diagnosis Related Group Diagnosis Related Group (DRG) 246-249 |
09.13.12 |
| Probe Medical Review of Cardiac Defibrillator Implant Without Cardiac Catheterization Without Major Complaints Co-morbidities (MCC) (DRG 227) |
03.08.12 |
| Probe Medical Review of Cellulitis without Major Complaints Co-morbidities (MCC) (MS DRG 603) Short Stay Dates of Service Less than Three Days |
02.22.12 |
| Probe Medical Review of Chronic Obstructive Pulmonary Disease without CC/MCC (DRG 192) |
04.18.12 |
| Probe Medical Review of Circulatory Disorders (DRG 287) |
04.12.12 |
| Probe Medical Review of Inpatient Closed Endoscopic Biopsy of Lung |
02.07.12 |
| Probe Medical Review of Inpatient Continuous Invasive Mechanical Ventilation for 96 Consecutive Hours or More |
02.01.12 |
| Probe Medical Review of Inpatient Principal Diagnosis for Other and Unspecified Coagulation Defect |
02.07.12 |
| Probe Medical Review of Kidney and Urinary Tract Infections without Major Complaints Co-morbidities (MCC) (DRG 690) |
03.08.12 |
| Probe Medical Review of Medical Back Problems without MCC Diagnosis Related Group (DRG) 552 |
08.01.12 |
| Probe Medical Review of Other Vascular Procedures without CC/MCC (DRG 254) and Other Vascular Procedures with CC (DRG 253) |
04.18.12 |
| Probe Medical Review of Outpatient Cardiac Rehabilitation with Continuous ECG Monitoring (93798) |
02.10.12 |
| Probe Medical Review of Outpatient Pulmonary Rehabilitation, Including Exercise (includes monitoring), One Hour, Therapeutic, Prophylactic or Diagnostic (G0424) |
02.10.12 |
| Probe Medical Review of Permanent Cardiac Pacemaker Implant (DRG 243 and DRG 244) |
04.12.12 |
| Probe Medical Review of Simple Pneumonia and Pleurisy without CC/MCC (DRG 195) |
04.18.12 |
| Probe Medical Review of Syncope and Collapse (DRG 312) |
03.08.12 |
| Pulmonary Rehabilitation: Coverage and Documentation Requirements |
03.08.13 |
| Responding to a Skilled Nursing Facility (SNF) Additional Documentation Request (ADR) |
09.27.11 |
| Review of Evaluation and Management Services Performed in the Emergency Department |
09.27.11 |
| Skilled Nursing Facilities (SNFs): Top Denial Reason Codes for Medical Review, October-December 2012 |
02.27.13 |
| Therapy Cap Exception |
09.07.12 |
| 2013 Therapy Cap Process |
03.14.13 |
| Top CERT Denial Reasons for Inpatient, Skilled Nursing Facilities, and Outpatient Claims |
03.22.12 |
