Review of Diagnostic Radiology: Chest X-Ray Services

Railroad Medicare's Medical Review (MR) unit is conducting a service-specific review of chest X-ray CPT® Codes 71045 (radiologic examination, chest, single view, frontal) and 71046 (radiologic examination, chest, two views, frontal and lateral). Our MR unit selected this code based on both external and internal data analysis indicating risk for over-utilization or claim errors.

The Medicare Part B benefits for diagnostic radiology, including chest X-ray, are for tests performed for diagnosis and treatment of a patient. Routine services are not covered.

Preparing for the Review
As a reminder to providers, regardless of the type of claims selected for review, coverage guidelines require that documentation contain the following:

• The place of service 
• The medical necessity and appropriateness of the services being provided
• That services furnished have been accurately reported
• The medical record should be complete and legible and include:
  • Beneficiary name
  • Date of service
  • Legible name and signature of the rendering provider, including credentials
     

Records under review must contain:
The physician who’s treating the beneficiary is the physician who furnishes the consultation, treats a beneficiary for a specific medical problem, and uses the results in the management of the beneficiary’s specific condition. The physician treating the beneficiary must order all diagnostic X-ray tests. Tests not ordered by the physician are not considered to be reasonable and necessary.

When completing progress notes, the physician should clearly indicate all tests to be performed. Documentation in the patient’s medical record must support the medical necessity for ordering the service(s) per Medicare guidelines. These medical records should be submitted in response to a request for documentation.

Keep these records available upon request:

• Progress notes or office notes
• Physician order/intent to order
• Test results
• Attestation/signature log for illegible signature(s)

Signature Requirements

• Unsigned physician orders or unsigned requisitions alone do not support physician intent to order
• Physicians should sign all orders for diagnostic services to avoid potential denials
• If the signature is missing on a progress note, which supports intent, the ordering physician may complete an attestation statement and submit it with the response
  • If the signature is illegible, an attestation statement or signature log is acceptable
  • Attestation statements are not acceptable for unsigned physician orders/requisitions

Multiple Components
Diagnostic radiology tests, such as chest X-rays, are one of the procedures which have two components for billing purposes. First there is the professional service (PC), meaning the work by the physician or nonphysician provider to interpret the test. Secondly is the technical portion (TC), or the performance of the actual chest X-ray using imaging equipment. 

Medicare Part B contractors, like the RRB SMAC, process claims for the PC portion from the provider who renders the interpretation. See our article explaining billing interpretation of PC portion with CPT® Modifier 26. Use modifier 26 when a physician interprets but does not perform the test.

The TC portion should be submitted to the contractor who covers technical radiology for the place-of-service (POS). There is an article on our website explaining use of the HCPCS Modifier TC modifier for billing the technical component. 

According to the Medicare Claims Processing Manual Chapter 13 on Radiology and Other Diagnostic Services (PDF), Part B Medicare ‘pays under the fee schedule for the TC of radiology services furnished to beneficiaries who are not patients of any hospital, and who receive services in a physician’s office, a freestanding imaging or radiation oncology center, or other setting that is not part of a hospital.’

Sometimes our providers perform both the TC and PC portions of the diagnostic test. In this case, the test may be billed globally, without a modifier. However, there are various scenarios which may require the TC and PC to be billed on separate lines. More information is available in our articles on each modifier.

An example is when billing both the PC and TC of a procedure and the TC was purchased from an outside entity. The provider bills the professional component (26) on one line of service and the technical component (TC) on a separate line. 

The Medicare claim processing manual contains instructions on billing claims for other POS to Part A contractors.

Conducting the Review
Our MR department will review claims and additional documentation to determine if the services billed were reasonable, necessary and correctly coded, based on Medicare’s coverage and coding guidelines. Remittance advice (RAs) will contain claim determination details. If claims are denied or paid at a lower level of service, notification will be displayed on the RA. MR will also send a “Claim Review Determination Letter” for each denied claim that explains MR’s findings.

If you disagree with a claim denial or payment, you can request a first level appeal. Information on this is available on the Appeals page. 

Since these reviews are conducted on both prepayment and postpayment reviews, denials on claims that were previously paid generally result in an overpayment. Once a provider has notice of an overpayment, a provider may submit an Overpayment appeal.

For further assistance, please contact our Provider Contact Center at 888–355–9165. Representatives are available from 8:30 a.m. to 4:30 p.m. in all time zones with the exception of PT, which receives service from 8 a.m. to 4 p.m. PT.

Additional Resources

• Chest X-ray Services Check List (PDF)
• CMS guidelines Diagnostic Radiology Tests, IOM Publication 100-02, Chapter 15, Section 80 (PDF)
• CMS IOM Publication 100-04, Chapter 13; Medicare Claims Processing Manual Chapter 13 — Radiology Services and Other Diagnostic Procedures (PDF)
• MLN Fact Sheet 905364 Complying with Medicare Signature Requirements (PDF)