Claim denials drive up the cost of healthcare and divert resources from the primary goal of delivering quality patient care. When it comes to radiology services, the vast majority of claim denials can be attributed to insufficient documentation of medical necessity for three types of studies.
Increased awareness of claims requirements among ordering clinicians, technologists and front office staff will help avoid denials from Medicare administrative contractors (MACs) and private insurance providers.
Each MAC or private insurer develops its own policies regarding coverage determinations – so there are variations with regard to specific requirements based on which administrator will process a given claim. However, ensuring claim approvals all boils down to documentation of medical necessity – that is providing a complete record a patient’s signs, symptoms and medical history to substantiate the services prescribed.
When it comes to radiology service claims, our most troublesome area includes three types of studies that account for as much as 80% of medical necessity denials in our teleradiology practice: chest X-ray exams, non-invasive cardiovascular studies, and bone density studies. Following are general guidelines for meeting administrators’ requirements for medical necessity. For a more comprehensive review of these topics check out my free webinar Avoid Radiology Claim Denials with Effective Medical Necessity Documentation.
1) Chest X-ray exams
We see the highest rates of denial among orders for pre-operative chest X-rays or chest X-rays that have been routinely performed on admission. When a chest X-ray is ordered, it must be documented that the patient has a pulmonary or a cardiac disease, or that specific signs or symptoms were reported or diagnosed indicating a potential issue with the heart, lungs or other organs in the chest cavity.
Facilities that follow a standard of ordering chest X-rays for patients upon admission or pre-operatively will likely experience high rates of denial.
2) Non-invasive cardiovascular studies
MACs have varied and extensive policies regarding non-invasive CV studies, which means they probably have seen a lot of inappropriate billing on these procedures. It also means they are more likely to scrutinize related claims. Be thorough in documenting the medical necessity of radiology studies for:
- Peripheral venous examinations, particularly deep vein thrombosis, chronic venous insufficiency and vein mapping. Signs and symptoms of medical necessity may include:
- Patient needing anticoagulation or invasive therapeutic procedures
- Evidence of arterial occlusion disease or venous disease
- Edema, tenderness, inflammation
- Hemoptysis, chest pain, dyspnea
- Major surgical procedure or trauma to the lower extremities, or concern about compromising veins to the extremities
- For chronic venous insufficiency, recurrent DVT or post-thrombotic syndrome
- For varicose veins, must be accompanied by significant pain or stasis dermatitis
- Extracranial arterial studies. Signs and symptoms may include:
- Localized symptoms, such as weakness of one side of the face, slurred speech or weakness of a limb
- Recent history of neurological or cerebrovascular event
- Evidence of blunt trauma or penetration to the neck
- Documentation of significant stenosis
- Peripheral arterial exams. Signs and symptoms may include:
- Limb ischemia, either acute or chronic
- Intermittent claudication, pain at rest, diminished pulses
- Ulcerations, gangrene
- Evidence of a thromboembolic event
- Blunt penetrating trauma
3) Bone density studies
Bone density studies have specific medical necessity criteria. Typically, these studies are ordered either for a woman who has been determined to be estrogen deficient and at a clinical risk for osteoporosis based on her medical history, or an individual with vertebral abnormalities that indicate the possibility of osteoporosis or osteopenia.
Administrators will take into account each patient’s drug therapy history when evaluating a bone density study claim. For example, if a patient is receiving a glucocorticoid, such as prednisone, they must be taking at least five milligrams per day and have been on that medication for a minimum of three months before the study is considered medically necessary.
It is essential that physicians provide a patient’s medications when ordering bone density studies, or there’s a high probability that the claim will later be denied.
While the three types of studies outlined above account for a large number of radiology claim denials, the bottom line is that greater diligence in documenting signs, symptoms and medical histories for every patient when ordering radiology services – or any diagnostic services – will reduce claim denials while improving patient care.
Sharon Roeder, BA, CPC
Director of Medical Coding Compliance, vRad
Certified Professional Coder since 1999, member, American Academy of Professional Coders. Bachelor’s degree in business administration, Ottawa University. Certification, Harold P. Freeman Institute for Patient Navigation.