What guidelines should the reviewer use to evaluate the sampling units?
As part of its Claims Review, a reviewer should ensure that the sampling units were correctly coded, submitted, and reimbursed. Documentation to make these determinations include, but are not limited to: national policies, local policies, CMS program memoranda, Medicare carrier or intermediary manuals or bulletins, medical records, claim forms, and any other supporting documentation. Only those sampling units for which payment (either full or partial) has been received should be included in the population from which the sample is selected.
Answer 17: As part of its billing review, the IRO should ensure that the sampling units were correctly coded, submitted, and reimbursed. Documentation to make these determinations include, but are not limited to: national policies, local policies, medical records, claim forms, and any other supporting documentation. Only those sampling units for which payment (either full or partial) has been received should be included in the population from which the sample is selected.
