Wiki Auditing Diagnostic (Radiology) Services

[clopez]

Good morning,

Currently I'm conducting an audit to validate all services renderd to our members. I work at a manage care plan and am reviewing the documentation submitted by the doctors to validate the services were rendered, and medical necessity was met.

My question is when validating xrays do we need to receive the actual images ie xray films to validate for the technical component of the service.

Under Diagnostic Ultrasounds the guidelines in the CPT state examinations require permanently recorded images. For these when the images weren't submitted, I'm denying the service and requesting recoupment unless the images are provided.

So what about chest xrays, and other radiologic xrays. I need guidance please and if any supporting resources can be provided, I would greatly apppreciate it.

Thank you,

 

[thomas7331]

I would think that would be something that your organization would determine and would perhaps be in the contracts that your participating physicians make with the managed care organization. Certainly the images do need to be permanently recorded in the medical record, but for audit purposes, it's not customary to request copies of those images since they don't serve any purpose to auditors who aren't trained to read them - wouldn't the interpretations and reports be sufficient proof that the test was in fact done? If I suspected fraud, I'd want to do an on-site review to make sure the images were there but I don't know why it would be necessary to see those images as part of a review - it can be costly to reproduce the images and an unnecessary burden to place on your providers to request them, and it could also alienate the providers that your plan probably needs to have to treat you plan's members.

 

[CodingKing]

Please tell me your are joking? If you are seriously denying imaging procedures where the image is not attached you should stop immediately. I've never worked at a carrier that would request copies of x-rays. I used to have to spend an hour a week contacting oral surgeon offices to stop sending us x-rays (maybe its something done in dental insurance

Thomas hit pretty much all the points i would make. I work for an insurance company and there is no way we would ever do what you are doing. If it were suspected fraud we would have someone pay the facility or office a visit. What you are doing is also looking for a needle in a haystack and a waste of time and effort for everybody. The time could be better much spent doing other things. How about looking for inappropriate use of modifier 59. Providers who seem they are billing way too high of a percentage of level 5 office visits. Maybe i could understand looking at the reports of repeat exams the same day to make sure they were really taken at 2 different times.

 

[clopez]

Thanks for the feedback, the only ones that I denied were for OB ultrasounds because for some patients we did get copies of the images but for others they were not included. Then I question the other imaging services in the Radiology section but haven't denied those services yet. Now with EHR I see xrays and EKGs getting scanned into the EHR so that's what sparked the question, and since we are paying for both the technical and professional component. Thanks

 

[CodingKing]

Unless you have a published policy that these need to be includes with all claims you should not be denying for them not being included.

 

[clopez]

The services are not being denied when they submit the claims. We conduct yearly audits to our providers to ensure documentation supports the services were rendered and that they meet medical necessity. This is happening during retrospective audits.