Description
Radiographs of the chest are common tests performed in many outpatient offices (radiology and many others), clinics, outpatient hospital departments, inpatient hospital episodes, skilled nursing facilities, homes, and other settings. They can be used for many pulmonary diseases, cardiac diseases, infections and inflammatory diseases, chest and upper abdominal trauma situations, malignant and metastatic diseases, allergic and drug related diseases. This review will ensure chest x-rays are paid when billed appropriately and only when medically necessary. Claims that are billed inappropriately or that do not meet medical necessity requirements will result in an overpayment.
Affected Code(s)
71045, 71046, 71047, 71048
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations
6. 42 CFR §405.986- Good Cause for Reopening
7. 42 CFR, §410.32, Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.
8. 42 CFR §411.15(a)(1) – Particular services excluded from coverage, (a) Routine physical checkups (1) Examinations performed for a purpose other than treatment or diagnosis of a specific illness, symptoms, complaint, or injury, except for screening
9. 42 CFR 486.100 - Condition for coverage: Compliance with Federal, State, and local laws and regulations
10. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §§80.4-80.4.4- Coverage of Portable X-Ray Services Not Under the Direct Supervision of a Physician
11. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §80.6.1- Definitions
12. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
13. Noridian Local Coverage Determination: L37547- Chest X-Ray Policy; Effective 6/22/2018; Revised 11/01/2019
14. Noridian Local Coverage Article (LCA): A57497- Billing and Coding: Chest X-Ray Policy, Effective 11/01/2019, Revised 10/01/2021
15. Noridian Local Coverage Determination: L37549- Chest X-Ray Policy; Effective 6/22/2018; Revised 11/01/2019
16. Noridian Local Coverage Article (LCA): A57498- Billing and Coding: Chest X-Ray Policy, Effective 11/01/2019, Revised 10/01/2021
17. AMA CPT Codebook