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March 27, 2012

Results of KY and OH Progressive Corrective Action for Advanced Imaging Services

The J15 CGS Medical Review Department recently completed a pre-pay review for Advanced Imaging Services. This review involved providers billing the Part B MAC for services such as CT scans and MRIs with and/or without contrast. If you provide these services, please review the information below to assist in correcting the errors and decrease the error rate for these services. Sharing this information with all staff involved with the provision, coding, billing and submission of medical records will also decrease the need for future appeals.

Medical Necessity Reasons for Denials:

Per the ASTRO/ACR Guidelines: Definition of medically necessary: Medically Necessary: Services or supplies that are proper and needed for the diagnosis, or treatment of a medical condition; are provided for the diagnosis, direct care and treatment of a medical condition; meet the standards of good medical practice in the local area; and are not mainly for the convenience of the patient or doctor. Having defined the services as provided for the diagnosis, direct care and treatment of the patient's medical condition, a key component of documentation to support the medical necessity of advanced imaging services shows how the services were used in the direct care and treatment of the patient

  1. Documentation submitted did not support the clinical indication for the testing. Most frequently CT scans of the head (70450) were performed in the absence of a fall; patient history or presenting signs and symptoms did not support a potential for cerebral bleed, stroke or other condition that would deem the CT of the head as medically reasonable and necessary. Results were within normal limits and the patient was discharged from the emergency department within hours after arrival.
  2. Documentation was insufficient to support services as billed-patient was an inpatient at time of service but only the emergency room record was sent. The inpatient records for the date and time of service were not sent to support the professional service.
  3. Beneficiary history indicates a billing pattern establishing frequent advanced imaging services but medical records do not substantiate the medical need for the frequency of services.

Record Submission/Response to Request Errors

  1. No order/documentation of intent for service
  2. No signature in records or on order
  3. Radiology report not properly signed
  4. Unable to identify the patient as a Medicare beneficiary
  5. No documents sent in response to Additional Development Request
  6. Billing error
    1. Wrong date of service
    2. Wrong service
    3. Duplicate service
    4. Beneficiary has other coverage as primary
  7. Records incorrect/incomplete
    1. Wrong records-only emergency room records sent when service is an inpatient; ambulance transport record only
    2. Incomplete radiology report
    3. No radiology report sent
    4. Illegible orders

Ways to Prevent these Errors

  1. Review internal policies (such as standing orders or emergency room standard protocols) for use of advanced imaging services.
  2. Provide adequate documentation to support the medical necessity requirements in the Code of Federal Regulations*.
  3. Obtain all signatures prior to submitting documentation.
  4. Request documentation from third parties as necessary.
  5. Respond completely and timely to records requests.
  6. Review American Academy of Professional Coding (AAPC) and American Medical Association (AMA) guidelines for coding and billing of advanced imaging services.
  7. Institute a quality process for accurate claims submissions.

*Per 42 CFR § 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions :(a) Ordering diagnostic tests. All diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary
Based on the above reference, using CTs or MRIs as screening tools or as a standard protocol is not appropriate without the medical necessity evident in the documentation for the advanced imaging procedure. Documentation to support medical necessity consists of:

  • Properly signed orders or properly signed clinical notes that clearly show an intent to order the test
  • Reasons for the diagnostic test such as signs, symptoms and results of or comparisons to previous data obtained. It is helpful when the radiology report clearly indicates the reason for the test. This should be considered for a quality process improvement.
  • Results of test including a properly signed interpretation.
  • If available, documents showing the utilization of the testing results in the follow-up care of the patient are helpful to the reviewer in establishing medical necessity

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