US · guidance
CMS Pub. 100-08, ch. 3, § 3.5.3
CMS Mandated Edits
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).
History
(Rev. 721; Issued: 06-09-17; Effective: 07-11-17; Implementation: 07-11-17)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
6f7a63541e674753d50d6504c14d494598993428e5f02e15824486fde41b2913
The link goes to the issuing authority’s own document — the one we read to produce this record. Where a source publishes whole titles rather than sections, your browser may need a moment to jump to the provision.
Unofficial copy of government-published law, reproduced from official sources with full provenance. Not an official publication; verify against official sources before relying on it in a filing. Records in the 'guidance' corpus, and only that corpus, are sub-regulatory (interpretive guidelines, survey procedures) and are not binding law. Validity bounds follow each jurisdiction's declared temporalBasis.