Unsatisfactory Documentation Tops the List in Claim Denials in Radiology

According to the Centers for Medicare & Medicaid Services (CMS) insufficient documentation resulted in more than 94 percent of the CERT review contractor-identified improper payments. Among them, half of the payment denials were cause by missing orders.


Radiology, in particular is a sensitive area because most procedures require a physician’s order. In 2014, Computed tomography (CT) scans had an improper payment rate of 13 percent for the Comprehensive Error Rate Testing (CERT) program. According to Medicare’s National Coverage Determination (NCD), NCD 220.1, CT scans needs to be medically appropriate according to the patient’s symptoms and diagnosis. Local Coverage Determinations (LCDs) for CT scans further elaborates the circumstances demonstrating medical necessity. Additionally, documentation must be available to Medicare upon request.


CMS Offers Tips For Ensuring Proper Documentation of CT Scans To Prevent Denials:

  1. Ensure the order from the ordering physician is signed and retain a copy in the patient’s medical record; also document that you performed a CT scan.
  1. Make sure you have the ordering practitioner’s progress notes or other medical record entries documenting why the CT scan is needed.


  1. Keep a report of the CT scan from the radiologist or interpreting physician.


CMS has also provided certain resources to assist in complying with Medicare’s policy for CT scans:


  1. The “Medicare National Coverage Determinations Manual,” NCD 220.1, which is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part4.pdf
  2. LCDs are available at https://www.cms.gov/Medicare/Coverage/DeterminationProcess/LCDs.html
  3. “Medicare Coverage of Imaging Services” Fact Sheet is at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Radiology_FactSheet_ICN907164.pdf

Source: CMS’s Medicare Learning Network

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