MAC's Tips for Getting Radiology Services Paid

If you’re having a hard time getting Medicare to pay for radiologic chest examinations claims, you’re in good company. In Southern California alone, Palmetto GBA recently reported a 46.3 percent charge denial rate. And that was just between the months of February and April of this year.
The Jurisdiction 1 Medicare administrative contractor (J1-MAC) recently reported these findings after completing a service-specific complex review for CPT® codes 71010 Radiologic examination, chest; single view, frontal and 71020 Radiologic examination, chest, 2 views, frontal and lateral. Out of 19,001 claims reviewed, 8,879 were denied.
Why all the denials? According to the Part B MAC for California, Hawaii, and Nevada, claims were denied due to documentation, or a lack there of:

• 47 percent of claims were missing a physician order
• 27 percent of claims were missing or had incomplete documentation for the date of service
• 9 percent of claims were missing a radiology report
• 7 percent of claims had incorrect, incomplete, or illegible patient identification or date of service

To ensure claims payment for these radiology services, Palmetto GBA recommends that you:

• Include the necessary orders from the referring physician or non-physician practitioner in all documentation submitted. Orders must be legibly signed by the referring provider. If the signature is illegible, the referring provider’s full name must be clearly printed or typed on the order, as well.
• Submit all documentation supporting the services billed within 30 days of the date on the additional documentation request (ADR) letter.
• Verify that all documentation is complete and all dates of service are included before billing.
• Include any additional information pertinent to the date of service to support the services billed: original chart notes, diagnostic, radiological, or laboratory results.
• Ensure that the complete radiology report signed by the rendering provider is included.
• Ensure all documentation contains correct patient and date of service information prior to submission.
• Ensure that patient identifiers are legible and complete.

Palmetto GBA says that, due to a moderate charge denial rate in southern California, they intend to review CPT® codes 71010 and 71020 for another quarter.
Source: Palmetto GBA probe review article, dated Sept. 8

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