CT of Abdomen and Chest Decision Tree
This set of questions will assist with review of documentation requirements:
1. If billed with modifier 26 for professional component: Is the report authored by a qualified provider? Including pulmonologist, radiologist, oncologist
2. Does the documentation include progress note or other entry to support reasonable indication for ordering scan?
Yes No
3. Does the diagnosis code correlate with the documentation and symptoms to support medical necessity of test?
Yes No
4. Is a signed copy of the report provided?
Yes No
5. Does the clinical note support a face to face visit with the patient present and participating?
Yes No
6. Does the claim history indicate recent testing for the same diagnosis? If yes, does the documentation include explanation for repeat testing?
Yes No
Repeat testing must be well-supported in the medical record describing the necessity for additional testing.
7. If CT with contrast is ordered, does the documentation indicate area or process being evaluated (i.e. nodule, effusion, mass etc.).
Yes No
8. Does the documentation support medical necessity if an excessive number of scans or unnecessarily expensive types of scans are billed?
Yes No
Excessive or unnecessarily expensive scans must be well-supported in the medical record describing the necessity for the scans.
9. Does documentation indicate tests performed include CT with AND without contrast?
Yes No
Please see correct CPT codes for billing CT with/without contrast.
10. If additional testing areas are ordered (i.e. CT chest AND abdomen), does documentation support suspected upper abdominal/chest pathology being evaluated?
Yes No
11. Does documentation indicate test ordered for screening purposes?
Yes No
12. Does the documentation include a signed order? If not, does the documentation include intent to order?
Yes No
13. Does all documentation meet signature requirements and include the name, signature and credentials of the person performing the service?
Yes No
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