Health Information Management

CT scan claims review finds 16% with improper payment rates

APCs Insider, May 9, 2014

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Recovery Auditors found that 16% of Medicare CT scan claims from July 2011 to June 2012 had an improper payment rate, according to the most recent Medicare Quarterly Provider Compliance Newsletter.
Insufficient documentation caused more than 99% of the improper payments. Some examples of insufficient documentation include:
  • No record of the billed service
  • No order or no evidence of intent to order
  • No physician’s signature on the order and no signature log or attestation
  • No results of a diagnostic test
More than half of the documentation errors resulted from missing orders. CMS lists its requirements for CT scans in National Coverage Determination 220.1, stating that scans must be medically appropriate considering the patient's symptoms and the preliminary diagnosis. Each provider’s Medicare Administrative Contractor may list further necessary documentation in its Local Coverage Determinations.
The newsletter provides specific examples of how missing documentation can result in overpayments. For example, it cites a case where a diagnostic radiologist billed CPT® code 71250 (CT, thorax; without contract material) for the professional service for interpreting and reporting a scan. The auditor received the results of the scan, but not an order from a treating physician or documentation to support the intent to order the scan or its medical necessity.
For more examples, as well as auditor findings on issues such as psychiatry and psychotherapy services, read the April 2014 newsletter.

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