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What everyone needs to know to ensure we all get paid

Claims management is essential to patient care. If a facility is not properly reimbursed for medical services rendered, patient care will ultimately be compromised.

When it comes to radiology services, often those on the front lines of patient care – the technologists, those scheduling imaging services, clinicians, and even our radiologists – aren't fully aware of how their decisions and practices impact claims and billing. All parties involved in patient care must commit to ongoing education and open communication.


It’s complicated

Centers for Medicare & Medicaid Services (CMS) establishes national coverage determinations (NCD) regarding medical items and services to be covered. In the absence of a NCD for a particular service, Medicare administrative contractors (MAC) may develop local coverage determinations (LCD) that define medical necessity for specific radiology services. Each of the MAC organizations develop their own LCD policies, which tend to be similar, but are not identical. Separately, private insurers develop policies which may differ from CMS coverage determinations.

As a result, there is no universal set of criteria that can be used to designate the medical necessity of every procedure or service. This complicates the claims process for coders and billers – and reporting requirements for clinicians and front-office staff. For example, based on a patient’s chief complaint, a radiologist may have a very different understanding of what may be medically necessary compared to determinations established by Medicare or third-party insurance payers. Some payer policies go beyond defining the medical conditions that support medical necessity by also imposing limits on how many times a provider may render a specific service within a specified time frame.

Now I don’t expect all physicians and technicians to be fully versed in every aspect of the claims process – any more than they would expect me to understand the nuances of an advanced neuroradiological study. It’s the responsibility of we coders to stay on top of shifting policies and practices. However, if a facility wishes to avoid claim denials, the billing department needs to provide the rest of the medical team with clear guidelines to follow to help ensure compliance.


Detail is a medical necessity

Coders know that a denied radiology claim is more likely due to a lack of information provided than to an overabundance of detail from the ordering provider. In fact, the lack of clinical history on radiology requisitions is a universal problem across all practices, resulting in a multitude of claim denials.

Clinicians and staff must be coached to provide, with every order, the patient’s presenting clinical condition, including detailed presenting symptoms and pertinent medical history. It is also helpful to describe underlying conditions – treatments, medications or disease progressions – and any complications that may contribute to the patient’s overall clinical picture.

Access to detail better enables the coder to connect each procedure to a specified medical necessity as required by the appropriate MAC or private administrator.

Moreover, a comprehensive clinical history allows the radiologist to make a more accurate and specific diagnosis. As Piotr Obara from the Department of Radiology at the University of Chicago put it, “The clinical history and indication provided with a radiologic examination are critical components of the quality interpretation by a radiologist.”

Bottom line: When ordering and reporting, detailed clinical histories improve patient care, and reduce claim denials.


Claims are everyone’s responsibility

Claim denials are a significant factor in the cost of healthcare. Medical staff and administrators need to work collaboratively to drive change.

Clinicians must practice diligence when ordering radiology studies to ensure every member of the care team has access to presenting conditions and thorough histories for each patient. Front office personnel who schedule procedures and services must recognize when they aren’t getting complete information and know when to ask questions. And billing administrators must proactively educate the medical team about requirements, while managing processes that enable efficient reporting of all relevant patient data.

For a more detailed exploration of this topic, check out my recorded webinar Avoid Radiology Claim Denials with Effective Medical Necessity Documentation, and watch for future webinars on this topic.


About the Author

Author Sharon Roeder, BA, CPC

Director of Medical Coding Compliance. 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.

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