Ensuring Compliance for Radiology Services 

Radiology services can be accompanied by some unique compliance challenges that do not always exist with other types of health care services.  The following tips can help compliance professionals as they develop strategies to monitor compliance associated with typical radiology services. 

Tip 1: Document Clinician Orders for Diagnostic Tests   

One of Medicare’s hospital conditions of participation requires that radiologic services must be provided only on the order of practitioners with clinical privileges or, consistent with State law, of other practitioners authorized by the medical staff and the governing body to order the services. Even outside the hospital setting, physician orders for diagnostic imaging tests are essential. In such cases, all diagnostic x-ray tests must be ordered by the physician who is treating the patient. In other words, tests must be ordered by the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary’s specific medical problem. Tests not ordered by the physician who is treating the patient are not reasonable and necessary. 

Tip 2: Document Medical Necessity for Imaging Services 

Medical necessity must be evidenced not only by the correct ICD-10 code but also by documentation in the patient’s medical record supporting the diagnosis and need for the test. Furthermore, frequency of services must be medically necessary based on initial inconclusive results, need for further diagnostic testing, measurement of efficacy of treatment (tumor growth/recession), or superiority of imaging techniques. 

Tip 3: Read, Understand, and Follow Local Coverage Determinations 

Local coverage determinations (LCDs) are policies published by Medicare Administrative Contractors (MAC) that usually contain detailed requirements and explanations for compliance Medicare coverage. Radiology services often have specific LCDs applicable to Medicare Coverage. It is essential that those entrusted with payment integrity duties ensure appropriate revenue cycle personnel read, understand, and follow LCDs. 

For example, one MAC issued an LCD for CT scans of the head. The LCD has very specific coverage requirements: 

“The ICD-10 codes R51.9 (Headache, unspecified) and G44.1 (Vascular headache, not elsewhere classified) will only be covered in the following situations: 

a. The patient is suffering from headaches and a head injury. Head computed tomography (CT) is performed to rule out the possibility of an intracranial bleed. 
b. The patient is suffering from headaches unusual in duration (greater than 2 weeks) not responding to medical therapy. Head CT is performed to rule out the possibility of a tumor. 
c. The patient is suffering from new onset headache (less than 2 weeks) suggestive of intracranial bleeding as evidenced by signs (e.g., weakness or paralysis), symptoms (e.g., blurred vision, nausea and vomiting), or clinical history. 

Any claim billed with ICD-10 code R51.9 (Headache, unspecified) or G44.1 (Vascular headache, not elsewhere classified) may be subject to manual review.” 

Understanding these types of coverage issues is essential for billing compliance professionals. 

Tip 4: Know the Rules for Teaching Physicians in Radiology 

Medicare pays for the interpretation of diagnostic radiology tests under the physician fee schedule (PFS) when a physician other than a resident physician (a.k.a. physician in training) performs it. They may also pay the PFS rate, only in residency training sites located outside a metropolitan statistical area (MSA), to a resident interpreting diagnostic radiology and other diagnostic tests when the teaching physician is present through audio-video real-time technology. Medical records must show the physician took part in interpreting diagnostic radiology tests. 

Radiology services have unique characteristics, and some unique compliance considerations that accompany them include compliance rules associated with physician orders, medical necessity, local coverage determinations, and teaching physician settings. Compliance professionals need to be aware of these and others as they develop strategies to follow rules and regulations associated with typical radiology services. 

Download a PDF Tip Sheet of this Article Below